Basic Information
| Provider Information | |||||||||
| NPI: | 1487877551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEMPLETON | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | HEATHER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCIAMBRA | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | HEATHER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 609 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261430609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042753301 | ||||||||
| FaxNumber: | 3042754798 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261641730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042731033 | ||||||||
| FaxNumber: | 3042731034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0078684 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 6796 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 28202 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD8227 | 05 | AK | MEDICAID |