Healthcare Provider Details

I. General information

NPI: 1801073812
Provider Name (Legal Business Name): STEPHANIE BROOKE PROVOST JOHNSTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE BROOKE PROVOST M.D.

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W FARIS RD SUITE 470
GREENVILLE SC
29605-4253
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-5938
  • Fax:
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number36228
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68041741205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: