Provider Demographics
NPI:1235647751
Name:OUTLAND, BONITA LOUISE
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:LOUISE
Last Name:OUTLAND
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 1:420 MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4888
Mailing Address - Country:US
Mailing Address - Phone:912-644-5202
Mailing Address - Fax:
Practice Address - Street 1:420 MALL BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4888
Practice Address - Country:US
Practice Address - Phone:912-644-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN097943163W00000X, 163WC0400X, 163WL0100X, 171M00000X, 364SW0102X
174H00000X
GARN079743364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN097943OtherNSG