Healthcare Provider Details

I. General information

NPI: 1689005993
Provider Name (Legal Business Name): STACEY JOHNSON APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 519
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 519
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-526-7017
  • Fax:
Mailing address:
  • Phone: 501-733-2967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberA003751
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: