Provider Demographics
NPI:1639647647
Name:BERMUDEZ VERA, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:BERMUDEZ VERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 B ST STE 1570
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4560
Mailing Address - Country:US
Mailing Address - Phone:619-615-0439
Mailing Address - Fax:
Practice Address - Street 1:2810 CAMINO DEL RIO S STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3819
Practice Address - Country:US
Practice Address - Phone:619-299-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95119476163WP0809X, 163WP0808X
390200000X
CA95017611363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program