Provider Demographics
NPI:1750140406
Name:JOHNSON, STACY ANN D
Entity type:Individual
Prefix:
First Name:STACY ANN
Middle Name:D
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 1:5471 N UNIVERSITY DR APT 7612
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5147
Mailing Address - Country:US
Mailing Address - Phone:954-248-8938
Mailing Address - Fax:
Practice Address - Street 1:5471 N UNIVERSITY DR APT 7612
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5147
Practice Address - Country:US
Practice Address - Phone:954-248-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9610615163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health