Provider Demographics
NPI:1164519971
Name:PENDLETON, BONNIE L (AUD, MS, MA)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:AUD, MS, MA
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:LYNN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4472
Mailing Address - Country:US
Mailing Address - Phone:580-558-8424
Mailing Address - Fax:
Practice Address - Street 1:4301 WILSON ST
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4472
Practice Address - Country:US
Practice Address - Phone:580-558-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2133235Z00000X
OK239231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100657760EMedicaid
OK100657760FMedicaid
OK100657760AMedicaid