Provider Demographics
NPI:1396133120
Name:JOHNSON-BUNDY, RAE DENISE (DOULA)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:DENISE
Last Name:JOHNSON-BUNDY
Suffix:
Gender:F
Credentials:DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 GLEN MOORE CIR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4030
Mailing Address - Country:US
Mailing Address - Phone:717-471-0668
Mailing Address - Fax:
Practice Address - Street 1:1442 GLEN MOORE CIR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4030
Practice Address - Country:US
Practice Address - Phone:717-471-0668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-01
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENNSYLVANIIAMedicaid
PAPENNSYLVANIIAMedicare UPIN