Provider Demographics
NPI:1710923982
Name:JOHNSON, STEPHANIE N (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-6102
Mailing Address - Country:US
Mailing Address - Phone:205-661-2080
Mailing Address - Fax:205-661-2085
Practice Address - Street 1:129 N CHALKVILLE RD
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1376
Practice Address - Country:US
Practice Address - Phone:205-445-2020
Practice Address - Fax:205-655-3194
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-B36152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist