Provider Demographics
NPI:1003497140
Name:KNOTTS, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:KNOTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MEDICAL PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9283
Mailing Address - Country:US
Mailing Address - Phone:804-609-0175
Mailing Address - Fax:
Practice Address - Street 1:34 MEDICAL PARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9283
Practice Address - Country:US
Practice Address - Phone:804-609-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator