Basic Information
| Provider Information | |||||||||
| NPI: | 1669401337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONNETT | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187080 | ||||||||
| FaxNumber: | 3367189622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 S HAWTHORNE RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367188386 | ||||||||
| FaxNumber: | 3367180290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 005001437 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 5001437 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0050 01437 | 01 | NC | MEDICAL BOARD LICENSE | OTHER | 2005010216 | 01 | FL | CERTIFICATION | OTHER |