Basic Information
| Provider Information | |||||||||
| NPI: | 1144298761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNER | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
| FaxNumber: | 6153279612 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294401 | ||||||||
| FaxNumber: | 6153279612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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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 | 163W00000X | 108041 | TN | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 3625507 | 05 | TN | MEDICAID |