Healthcare Provider Details

I. General information

NPI: 1912736141
Provider Name (Legal Business Name): MARTHA STACY JOHNSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W ALTO RD
KOKOMO IN
46902-4907
US

IV. Provider business mailing address

702 W ALTO RD
KOKOMO IN
46902-4907
US

V. Phone/Fax

Practice location:
  • Phone: 317-876-3699
  • Fax:
Mailing address:
  • Phone: 317-876-3699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71015636A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: