Provider Demographics
NPI:1821262429
Name:JOHNSON, STACEY SMITH (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:SMITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 ALI WAY CREEKSIDE SOUTH
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203
Mailing Address - Country:US
Mailing Address - Phone:256-832-4141
Mailing Address - Fax:
Practice Address - Street 1:96 ALI WAY CREEKSIDE SOUTH
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203
Practice Address - Country:US
Practice Address - Phone:256-832-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered