Provider Demographics
NPI:1801073812
Name:PROVOST JOHNSTON, STEPHANIE BROOKE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BROOKE
Last Name:PROVOST JOHNSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:BROOKE
Other - Last Name:PROVOST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:SUITE 470
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4253
Practice Address - Country:US
Practice Address - Phone:864-455-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC362282080H0002X
UT68041741205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC362280Medicaid