Provider Demographics
NPI:1386212009
Name:JOHNSON, STACEY A
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 OAKWOOD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-1708
Mailing Address - Country:US
Mailing Address - Phone:518-274-6525
Mailing Address - Fax:
Practice Address - Street 1:289 OAKWOOD AVE STE C
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-1708
Practice Address - Country:US
Practice Address - Phone:518-274-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278273164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse