Basic Information
| Provider Information | |||||||||
| NPI: | 1407121577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHON | ||||||||
| FirstName: | BRIE | ||||||||
| MiddleName: | FONDA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1330 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653553431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604281280 | ||||||||
| FaxNumber: | 6604281283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653553431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604281280 | ||||||||
| FaxNumber: | 6604281283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 149469 | MO | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.