Provider Demographics
NPI:1861592875
Name:JOHNSON, STACY MAE (DC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992-1520
Mailing Address - Country:US
Mailing Address - Phone:507-732-7455
Mailing Address - Fax:507-732-7455
Practice Address - Street 1:118 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ZUMBROTA
Practice Address - State:MN
Practice Address - Zip Code:55992-1520
Practice Address - Country:US
Practice Address - Phone:507-732-7455
Practice Address - Fax:507-732-7455
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6C412FAOtherBLUE CROSS BLUE SHIELD OF
MN6C412FAOtherBLUE CROSS BLUE SHIELD OF