Provider Demographics
NPI:1760188411
Name:JOHNSON, STACIE RENEE
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 E 15TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8768
Mailing Address - Country:US
Mailing Address - Phone:970-461-1975
Mailing Address - Fax:
Practice Address - Street 1:3780 E 15TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8768
Practice Address - Country:US
Practice Address - Phone:970-461-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator