Provider Demographics
NPI:1619621141
Name:JOHNSON, STEPHANIE CANDICE (LPN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CANDICE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 CENTRAL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-3374
Mailing Address - Country:US
Mailing Address - Phone:352-678-9988
Mailing Address - Fax:
Practice Address - Street 1:6204 CENTRAL CHURCH RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3374
Practice Address - Country:US
Practice Address - Phone:352-678-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5228622164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse