Provider Demographics
NPI:1881700896
Name:MACDONALD, M. BERNADETTE (APRN-PMH)
Entity type:Individual
Prefix:MS
First Name:M.
Middle Name:BERNADETTE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:APRN-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5182
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22194-5182
Mailing Address - Country:US
Mailing Address - Phone:703-408-0727
Mailing Address - Fax:
Practice Address - Street 1:12584 DARBY BROOK CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2485
Practice Address - Country:US
Practice Address - Phone:703-408-0727
Practice Address - Fax:703-491-2388
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00015000723364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP74732Medicare UPIN