Provider Demographics
NPI:1174006753
Name:BONNER, CARLY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6926 10 TIMBERS LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-1637
Mailing Address - Country:US
Mailing Address - Phone:267-535-0473
Mailing Address - Fax:
Practice Address - Street 1:14700 BALTIMORE AVE UNIT 106
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4878
Practice Address - Country:US
Practice Address - Phone:267-535-0473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program