MEDICARE: STACY L JOHNSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	28140959A	IN
2	363LF0000X	Family Nurse Practitioner	71002173A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417907189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY L JOHNSON NP

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 E DUPONT RD STE 226
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1603
Country	:	US
Telephone Number	:	260-460-3100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	11/20/2023

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