Basic Information
| Provider Information | |||||||||
| NPI: | 1306461868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BAILEY | ||||||||
| MiddleName: | ANNETTE | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9214 ARCH STREET PL | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357585526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2566530739 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 306 WYNN DR NW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358051961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568822457 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2020 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 300382912 | 01 | AL | NON MEDICARE | OTHER |