Provider Demographics
NPI:1497375885
Name:BONNER, GABRIELLE ALEXIA
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ALEXIA
Last Name:BONNER
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 1:1694 TORRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2332
Mailing Address - Country:US
Mailing Address - Phone:901-412-8575
Mailing Address - Fax:
Practice Address - Street 1:1694 TORRINGTON CT
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2332
Practice Address - Country:US
Practice Address - Phone:901-412-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant