Basic Information
| Provider Information | |||||||||
| NPI: | 1619961620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYCOCK | ||||||||
| FirstName: | BONITA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7200 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524510056 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 DODD ST | ||||||||
| Address2: | |||||||||
| City: | SPRING HOPE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278829348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524785412 | ||||||||
| FaxNumber: | 2529373100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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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 | 363L00000X | 200892 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500005810 | 01 | NC | RAILROAD MEDICARE | OTHER | 1619961620 | 01 | NC | NPI | OTHER | 58594 | 01 | NC | MEDICAL LICENSE | OTHER | 7000422 | 05 | NC | MEDICAID | MA0277043 | 01 | NC | DEA | OTHER | 363L00000X | 01 | NC | TAXONOMY | OTHER |