Provider Demographics
NPI:1740564228
Name:JOHNVILLE, STACEY LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:JOHNVILLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:PETTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3820 MYSTIC MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9549
Mailing Address - Country:US
Mailing Address - Phone:315-589-4028
Mailing Address - Fax:
Practice Address - Street 1:3820 MYSTIC MEADOWS LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9549
Practice Address - Country:US
Practice Address - Phone:315-589-4028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY623319-1163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health