Provider Demographics
NPI:1114605607
Name:JOHNSON, STEPHANIE JOAN (BA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JOAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JOAN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:1440 E WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2552
Practice Address - Country:US
Practice Address - Phone:608-745-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator