Provider Demographics
NPI:1275931214
Name:BINGHAM, BONNIE I
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:BINGHAM
Suffix:I
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 1:122 WILDWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1617
Mailing Address - Country:US
Mailing Address - Phone:631-368-6464
Mailing Address - Fax:
Practice Address - Street 1:122 WILDWOOD CIR
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-1617
Practice Address - Country:US
Practice Address - Phone:631-368-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY626519-1163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY163W00000XOtherRN