Provider Demographics
NPI:1801815709
Name:JOHNSON, MARYELLEN (CNM)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 HAWLEY ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-3903
Mailing Address - Country:US
Mailing Address - Phone:607-723-8306
Mailing Address - Fax:607-723-4087
Practice Address - Street 1:117 HAWLEY ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-3903
Practice Address - Country:US
Practice Address - Phone:607-723-8306
Practice Address - Fax:607-723-4087
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010128367A00000X
NY203483-1367A00000X
NYF360105-1363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
R55747Medicare UPIN