Provider Demographics
NPI:1750967261
Name:JOHNSON, TAI AYOOLA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TAI
Middle Name:AYOOLA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TAIWO
Other - Middle Name:AYOOLA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:841 CASLON WAY APT 208
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-6001
Mailing Address - Country:US
Mailing Address - Phone:951-251-9836
Mailing Address - Fax:
Practice Address - Street 1:7877 WILLOW CHASE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-6001
Practice Address - Country:US
Practice Address - Phone:832-869-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCR226582363LP0808X
TX1098932363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health