Provider Demographics
NPI:1346840089
Name:BAYONNE, OPAL GLORIEN (APRN)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:GLORIEN
Last Name:BAYONNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 MAPLE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2487
Mailing Address - Country:US
Mailing Address - Phone:678-628-3919
Mailing Address - Fax:
Practice Address - Street 1:3430 MAPLE TERRACE DR
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2487
Practice Address - Country:US
Practice Address - Phone:678-628-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily