Provider Demographics
NPI:1407275506
Name:JOHNSON, STACIE LEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BERRY ST PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093
Mailing Address - Country:US
Mailing Address - Phone:774-219-4588
Mailing Address - Fax:
Practice Address - Street 1:74 BERRY ST
Practice Address - Street 2:
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093-1522
Practice Address - Country:US
Practice Address - Phone:774-219-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN86901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse