Basic Information
| Provider Information | |||||||||
| NPI: | 1801815709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 HAWLEY ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139013903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077238306 | ||||||||
| FaxNumber: | 6077234087 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 HAWLEY ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139013903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077238306 | ||||||||
| FaxNumber: | 6077234087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | MW010128 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 203483-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LX0001X | F360105-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
No ID Information.