Basic Information
| Provider Information | |||||||||
| NPI: | 1255647061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534900 | ||||||||
| FaxNumber: | 5024895750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 KRESGE WAY STE 56 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028957265 | ||||||||
| FaxNumber: | 5028972032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3006615 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100136300 | 05 | KY | MEDICAID |