Healthcare Provider Details

I. General information

NPI: 1366371031
Provider Name (Legal Business Name): STACY LEE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8325 2ND ST NW STE B
LOS RANCHOS NM
87114-1013
US

IV. Provider business mailing address

1307 RICHMOND DR NE UNIT A
ALBUQUERQUE NM
87106-1808
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-3655
  • Fax:
Mailing address:
  • Phone: 505-288-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: