Healthcare Provider Details

I. General information

NPI: 1366459661
Provider Name (Legal Business Name): STACEY LANETTE JOHNSON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/10/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MEDICAL CENTER ROAD
FORT CAVAZOS TX
76544
US

IV. Provider business mailing address

58TH STREET BUILDING 36029
FORT CAVAZOS TX
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-287-8179
  • Fax:
Mailing address:
  • Phone: 254-287-8179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number12356
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: