Provider Demographics
NPI:1568248201
Name:BOHANNON, THERESE JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:JEAN
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3400
Mailing Address - Country:US
Mailing Address - Phone:202-849-5619
Mailing Address - Fax:
Practice Address - Street 1:11100 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3400
Practice Address - Country:US
Practice Address - Phone:202-389-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR138795163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health