Provider Demographics
NPI:1346594959
Name:PONDER, BONITA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:
Last Name:PONDER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 LOGANVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7715
Mailing Address - Country:US
Mailing Address - Phone:770-277-5996
Mailing Address - Fax:
Practice Address - Street 1:2720 LOGANVILLE HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7715
Practice Address - Country:US
Practice Address - Phone:770-277-5996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily