Provider Demographics
NPI:1679242887
Name:JOHNSON, BAILEY BODELL (PMHNP)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:BODELL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 MOUNT VISTA RD
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21087-1728
Mailing Address - Country:US
Mailing Address - Phone:301-467-0907
Mailing Address - Fax:
Practice Address - Street 1:4350 E WEST HWY STE 200
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4426
Practice Address - Country:US
Practice Address - Phone:301-970-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR222740363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty