Provider Demographics
NPI:1093363061
Name:JOHNSON, BRYA KIMNITA (MSW)
Entity type:Individual
Prefix:
First Name:BRYA
Middle Name:KIMNITA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 BERTHOLD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-2409
Practice Address - Country:US
Practice Address - Phone:314-643-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula