Provider Demographics
NPI:1851757694
Name:JOHNSON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
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:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:IVEL
Mailing Address - State:KY
Mailing Address - Zip Code:41642-0197
Mailing Address - Country:US
Mailing Address - Phone:606-478-8500
Mailing Address - Fax:606-478-8505
Practice Address - Street 1:346 SUNSHINE LN
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3115
Practice Address - Country:US
Practice Address - Phone:606-478-8500
Practice Address - Fax:606-478-8505
Is Sole Proprietor?:No
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator