Basic Information
| Provider Information | |||||||||
| NPI: | 1750931655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONNER MEDICAL AND BEHAVIORAL HEALTH SPECIALISTS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5777 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378025777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1288 MILL CREEK CV | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381347820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2019 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | BONNER | ||||||||
| AuthorizedOfficialFirstName: | CHARLENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8652462104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.