Healthcare Provider Details

I. General information

NPI: 1407077241
Provider Name (Legal Business Name): TRACI N JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI N BENNETT M.D.

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-3890
  • Fax:
Mailing address:
  • Phone: 417-820-3890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2009014099
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: