=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295897015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE JOHNSON OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 01/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BRULE ST
-----------------------------------------------------
City | FORT KNOX
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40121-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-626-9993
-----------------------------------------------------
Fax | 502-624-0482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2702 BRADEN WAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-8572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-913-1091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1649DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------