Provider Demographics
NPI:1407994601
Name:FAUGHN, BONNIE SUE
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:SUE
Last Name:FAUGHN
Suffix:
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 1:2342 COUNTY ROAD 523
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8017
Mailing Address - Country:US
Mailing Address - Phone:573-686-6142
Mailing Address - Fax:
Practice Address - Street 1:2342 COUNTY ROAD 523
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8017
Practice Address - Country:US
Practice Address - Phone:573-686-6142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities