Basic Information
| Provider Information | |||||||||
| NPI: | 1306031729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAHARESTANI | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | MYLENE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, APN, CWOCN, CWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | LAMONT AND SYDNEY ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | LAMONT AND SYDNEY ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 05/01/2015 | ||||||||
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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 | 163WC1600X | 1086300 | TN | N | Nursing Service Providers | Registered Nurse | Continuing Education/Staff Development | 163WE0900X | 1086300 | TN | N | Nursing Service Providers | Registered Nurse | Enterostomal Therapy | 163WW0000X | 1086300 | TN | N | Nursing Service Providers | Registered Nurse | Wound Care | 1744R1102X | F301205-1 | NY | N | Other Service Providers | Specialist | Research Study | 363L00000X | F301205-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | 1086300 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 363LA2200X | F301205-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.