Provider Demographics
NPI:1669126173
Name:JOHNSON, STEPHANIE MAE (APRN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 OATFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-2306
Mailing Address - Country:US
Mailing Address - Phone:859-319-3977
Mailing Address - Fax:
Practice Address - Street 1:844 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-2140
Practice Address - Country:US
Practice Address - Phone:859-605-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017377363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily