Provider Demographics
NPI:1699208553
Name:JOHNSON, STACY MICHELE (RN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MICHELE
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 1:1934 PARKER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-9161
Mailing Address - Country:US
Mailing Address - Phone:937-588-5203
Mailing Address - Fax:
Practice Address - Street 1:1934 PARKER RIDGE RD
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-9161
Practice Address - Country:US
Practice Address - Phone:937-588-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN386276163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse