Provider Demographics
NPI:1497791115
Name:CONNER, BONITA FAYE (FNP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:FAYE
Last Name:CONNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 290TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUBUN
Mailing Address - State:MN
Mailing Address - Zip Code:56589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40520 CO HWY 34
Practice Address - Street 2:WHITE EARTH HEALTH CENTER
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6217
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1180880363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
585241045697OtherPREFERRED ONE
0121298OtherMEDICA
376G7C0OtherBCBS
P59452Medicare UPIN
8HD795Medicare ID - Type Unspecified
585241045697OtherPREFERRED ONE
8HD794Medicare ID - Type Unspecified