Basic Information
| Provider Information | |||||||||
| NPI: | 1013987338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNER | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | CHERYL | ||||||||
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| Credential: | PT CWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8939 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338068939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636179400 | ||||||||
| FaxNumber: | 8636889858 | ||||||||
| Practice Location | |||||||||
| Address1: | 1057 S FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338031114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636179400 | ||||||||
| FaxNumber: | 8636889858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT14391 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT14391 | 01 | FL | PT LICENSE | OTHER |