Provider Demographics
NPI:1417680828
Name:JOHNSON, STACEY CATHERINE (RN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:CATHERINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 IMLAY CITY RD
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48412-9797
Mailing Address - Country:US
Mailing Address - Phone:810-358-8238
Mailing Address - Fax:
Practice Address - Street 1:2525 DEMILLE BLVD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3461
Practice Address - Country:US
Practice Address - Phone:810-245-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704334876163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse