Provider Demographics
NPI:1770823718
Name:JOHNSON, STEPHANIE ROSE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HOLLAND LANE, APT 422
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314
Mailing Address - Country:US
Mailing Address - Phone:510-410-6032
Mailing Address - Fax:
Practice Address - Street 1:5105-A BACKLICK ROAD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003
Practice Address - Country:US
Practice Address - Phone:703-642-8685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor