Healthcare Provider Details

I. General information

NPI: 1851328900
Provider Name (Legal Business Name): STACEY JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY CAMPBELL

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 KY HIGHWAY 699
CORNETTSVILLE KY
41731
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858
US

V. Phone/Fax

Practice location:
  • Phone: 606-476-2593
  • Fax: 606-476-2347
Mailing address:
  • Phone: 606-633-4823
  • Fax: 606-633-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38781
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: