Provider Demographics
NPI:1912131236
Name:JOHNSON, STACY ALANA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ALANA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 EASTMORELAND AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3519
Mailing Address - Country:US
Mailing Address - Phone:901-448-5227
Mailing Address - Fax:
Practice Address - Street 1:1325 EASTMORELAND AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3519
Practice Address - Country:US
Practice Address - Phone:901-448-5227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN158299207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022744Medicaid
MS04171535Medicaid
GA003180105AMedicaid
AR225514001Medicaid
AL191144Medicaid
MO1912131236Medicaid