Provider Demographics
NPI:1174002232
Name:JOHNSON, STACY L (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 JONATHAN CODY DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-6877
Mailing Address - Country:US
Mailing Address - Phone:314-608-5726
Mailing Address - Fax:314-842-2552
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:888-256-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018018396363LF0000X
MO2020034563363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420064105Medicaid
363LP0808XOtherTAXONOMY