Provider Demographics
NPI:1831189554
Name:JOHNSTON, STEFANI (NP)
Entity type:Individual
Prefix:
First Name:STEFANI
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 E DUPONT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1675
Mailing Address - Country:US
Mailing Address - Phone:260-432-4400
Mailing Address - Fax:260-969-6898
Practice Address - Street 1:2512 E DUPONT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1675
Practice Address - Country:US
Practice Address - Phone:260-432-4400
Practice Address - Fax:260-969-6898
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28113743A163W00000X
IN71000852A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200338290Medicaid
IN259990SMedicare PIN
INP06934Medicare UPIN