Provider Demographics
NPI:1285815548
Name:BONOM, SANDRA J (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:J
Last Name:BONOM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7514
Mailing Address - Country:US
Mailing Address - Phone:601-829-3734
Mailing Address - Fax:
Practice Address - Street 1:126 PINE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7514
Practice Address - Country:US
Practice Address - Phone:601-829-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR100760364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health