Provider Demographics
NPI:1851328900
Name:JOHNSON, STACEY (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:464 KY HIGHWAY 699
Practice Address - Street 2:
Practice Address - City:CORNETTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41731
Practice Address - Country:US
Practice Address - Phone:606-476-2593
Practice Address - Fax:606-476-2347
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64881600Medicaid
KY64881600Medicaid
H96651Medicare UPIN