Provider Demographics
NPI:1184046096
Name:BODINE, JOHANNA CONGLETON (CNM)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:CONGLETON
Last Name:BODINE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:CONGLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 N WASHINGTON AVE STE 2700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1735
Mailing Address - Country:US
Mailing Address - Phone:214-975-3937
Mailing Address - Fax:469-309-7787
Practice Address - Street 1:411 N WASHINGTON AVE STE 2700
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1735
Practice Address - Country:US
Practice Address - Phone:214-975-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCNM1795367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345080101Medicaid
TXAP124942OtherAPRN
TX15228OtherRX AUTH #
TX744687OtherNURSE LICENSE #
TX744687OtherNURSE LICENSE #