Provider Demographics
NPI:1366459661
Name:JOHNSON, STACEY LANETTE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LANETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SPRINGFOREST CIR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5541
Mailing Address - Country:US
Mailing Address - Phone:843-424-2800
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU72073Medicare UPIN
SCU720730281Medicare ID - Type Unspecified
SCU720730281Medicare ID - Type Unspecified