Basic Information
Provider Information | |||||||||
NPI: | 1679709554 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONNER | ||||||||
FirstName: | TRACIE | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BONER | ||||||||
OtherFirstName: | TRACIE | ||||||||
OtherMiddleName: | F | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 122 CENTER ST | ||||||||
Address2: |   | ||||||||
City: | CLAY | ||||||||
State: | WV | ||||||||
PostalCode: | 250437046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045877301 | ||||||||
FaxNumber: | 3045872464 | ||||||||
Practice Location | |||||||||
Address1: | 122 CENTER ST | ||||||||
Address2: |   | ||||||||
City: | CLAY | ||||||||
State: | WV | ||||||||
PostalCode: | 250437046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045877301 | ||||||||
FaxNumber: | 3045872464 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2009 | ||||||||
LastUpdateDate: | 09/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 52119 | WV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1679709554 | 05 | WV |   | MEDICAID | 52119 | 01 | WV | STATE NP LICENSE | OTHER |