Provider Demographics
NPI:1467894220
Name:JOHNSON, STACY LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58541-7131
Mailing Address - Country:US
Mailing Address - Phone:701-870-0693
Mailing Address - Fax:
Practice Address - Street 1:420 CTY RD. 26
Practice Address - Street 2:
Practice Address - City:BEULAH
Practice Address - State:ND
Practice Address - Zip Code:58523
Practice Address - Country:US
Practice Address - Phone:701-873-6788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily