Provider Demographics
NPI:1497704472
Name:MACKIN, BONNIE JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:MACKIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 OLD ALVIN RD
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581
Mailing Address - Country:US
Mailing Address - Phone:281-997-2623
Mailing Address - Fax:
Practice Address - Street 1:5445 LA BRANCH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6835
Practice Address - Country:US
Practice Address - Phone:713-525-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX443088367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX443088OtherNURSING LICENSE