Stacey Lynn Johnville, RN

Primary specialty

Registered NurseTaxonomy code 163W00000X

License

623319-1 Issued in NY

Practice address

3820 Mystic Meadows LN
Williamson, NY 14589-9549

Phone

(315) 589-4028

NPI assigned

Oct 3, 2011

Last updated

Oct 3, 2011By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Miss Stacey Lynn Petterson Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Registered Nurse

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1317600000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1317600000000",
    "number": "1740564228",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3820 MYSTIC MEADOWS LN",
            "city": "WILLIAMSON",
            "state": "NY",
            "postal_code": "145899549",
            "telephone_number": "315-589-4028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3820 MYSTIC MEADOWS LN",
            "city": "WILLIAMSON",
            "state": "NY",
            "postal_code": "145899549",
            "telephone_number": "315-589-4028"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNVILLE",
        "first_name": "STACEY",
        "middle_name": "LYNN",
        "name_prefix": "Mrs.",
        "credential": "RN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2011-10-03",
        "last_updated": "2011-10-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NY",
            "license": "623319-1",
            "primary": true
        },
        {
            "code": "163WH0200X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Home Health",
            "state": "NY",
            "license": "623319-1",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "STACEY",
            "last_name": "PETTERSON",
            "middle_name": "LYNN",
            "prefix": "MISS",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Registered Nurse in Williamson, NY
• Providers in Williamson, NY by specialty
• Registered Nurse in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.