MEDICARE: BAYLEE RHAE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HID174M53590	OTHER	VA	ATHLETIC TRAINER

General Provider Information

NPI Number	:	1174220545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAYLEE RHAE JOHNSON

Provider Business Mailing Address
First Line	:	2132 MONUMENT DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-9014
Country	:	US
Telephone Number	:	760-885-5952
Fax Number	:

Provider Business Practice Location Address
First Line	:	8109 LUKE CT
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-6344
Country	:	US
Telephone Number	:	760-885-5952
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2023
Last Update Date	:	02/15/2023

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