Provider Demographics
NPI:1053532887
Name:JOHNSON, STACY D (RN)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:DEAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:56 EAST AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-4323
Practice Address - Country:US
Practice Address - Phone:512-703-1365
Practice Address - Fax:512-703-1390
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX610846163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse