Basic Information
| Provider Information | |||||||||
| NPI: | 1386026557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405323534 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 TOWNSHIP ROAD 508 E | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456807276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403772712 | ||||||||
| FaxNumber: | 7403772588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 09/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009364 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 019848 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0136069 | 05 | OH | MEDICAID | 7100354810 | 05 | KY | MEDICAID | 3810029959 | 05 | WV | MEDICAID |