Provider Demographics
NPI:1407339989
Name:JOHNSON, HALEY BASS
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:BASS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:783 OLD HICKORY BLVD # 360
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4508
Mailing Address - Country:US
Mailing Address - Phone:629-203-7925
Mailing Address - Fax:
Practice Address - Street 1:783 OLD HICKORY BLVD # 360
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4508
Practice Address - Country:US
Practice Address - Phone:629-203-7925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
TNI000000022984372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN080424817OtherDRIVERS LICENSE