Healthcare Provider Details

I. General information

NPI: 1104554302
Provider Name (Legal Business Name): STEPHANIE DEANN JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHLAND MEDICAL PARK DR STE 100
COLUMBIA SC
29203-6834
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6095
  • Fax: 803-758-0120
Mailing address:
  • Phone: 864-522-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number27180
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number232093
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: