Provider Demographics
NPI:1265175202
Name:DOUGLAS, BRYONNA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:BRYONNA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8288 TABOR LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-3057
Mailing Address - Country:US
Mailing Address - Phone:808-722-2865
Mailing Address - Fax:
Practice Address - Street 1:3024 CORIANDER PL
Practice Address - Street 2:
Practice Address - City:BRYANS ROAD
Practice Address - State:MD
Practice Address - Zip Code:20616-7048
Practice Address - Country:US
Practice Address - Phone:808-722-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001301512163WP0808X
VA0024185517363LP0808X
MDR262900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health