Provider Demographics
NPI:1700316270
Name:JOHNSON, STACEY GWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:GWEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:GWEN
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:402 N KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6986
Mailing Address - Country:US
Mailing Address - Phone:573-499-6084
Mailing Address - Fax:573-499-6088
Practice Address - Street 1:402 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6986
Practice Address - Country:US
Practice Address - Phone:573-499-6084
Practice Address - Fax:573-499-6088
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017018527207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2500041069OtherMISSOURI LICENSE