Provider Demographics
NPI:1649804337
Name:JOHNS, STACY ELLEN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ELLEN
Last Name:JOHNS
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 1:720 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5305
Mailing Address - Country:US
Mailing Address - Phone:918-685-0472
Mailing Address - Fax:
Practice Address - Street 1:433 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6614
Practice Address - Country:US
Practice Address - Phone:918-687-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator