Provider Demographics
NPI:1366484842
Name:TITCOMB, BONNI G (ARNP)
Entity Type:Individual
Prefix:
First Name:BONNI
Middle Name:G
Last Name:TITCOMB
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:1577 ROBERTS DR
Practice Address - Street 2:SIOTE 323
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3264
Practice Address - Country:US
Practice Address - Phone:904-241-9775
Practice Address - Fax:904-249-3638
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 624442363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308691700Medicaid
FLE6575ZMedicare PIN
FLE6575YMedicare PIN