Healthcare Provider Details

I. General information

NPI: 1174002232
Provider Name (Legal Business Name): STACY L JOHNSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SPENCER RD STE 201
SAINT PETERS MO
63376-2576
US

IV. Provider business mailing address

751 JONATHAN CODY DR
WENTZVILLE MO
63385-6877
US

V. Phone/Fax

Practice location:
  • Phone: 636-939-2550
  • Fax:
Mailing address:
  • Phone: 314-608-5726
  • Fax: 314-842-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018018396
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2020034563
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: