Provider Demographics
NPI:1841844685
Name:JOHNSON, STEPHANIE ANN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:JOHNSON
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 1:166 ARENA RD
Mailing Address - Street 2:
Mailing Address - City:ANIMAS
Mailing Address - State:NM
Mailing Address - Zip Code:88020-9358
Mailing Address - Country:US
Mailing Address - Phone:915-525-9569
Mailing Address - Fax:
Practice Address - Street 1:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Practice Address - Street 2:3600 N. GARFIELD
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705
Practice Address - Country:US
Practice Address - Phone:915-525-9569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13994363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program