Provider Demographics
NPI:1437648946
Name:JOHNSON, STEPHANIE MICHELE (MSN, RN, APRN, NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN, RN, APRN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12376 NW BARNES RD APT 338
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6050
Mailing Address - Country:US
Mailing Address - Phone:971-732-6255
Mailing Address - Fax:
Practice Address - Street 1:3560 SE 79TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2372
Practice Address - Country:US
Practice Address - Phone:503-775-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201800347NP-PP363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health