Provider Demographics
NPI:1306031729
Name:BAHARESTANI, MONA MYLENE (PHD, APN, CWOCN, CWS)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:MYLENE
Last Name:BAHARESTANI
Suffix:
Gender:F
Credentials:PHD, APN, CWOCN, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAMONT AND SYDNEY ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37684
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:
Practice Address - Street 1:LAMONT AND SYDNEY ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1086300163WC1600X, 163WE0900X, 163WW0000X, 364S00000X
NYF301205-11744R1102X, 363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No1744R1102XOther Service ProvidersSpecialistResearch Study
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist