Provider Demographics
NPI:1497876379
Name:BURKE, BONNIE
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:
Last Name:BURKE
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 1:16097 ROCKY TOP RDG
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4981
Mailing Address - Country:US
Mailing Address - Phone:423-844-4290
Mailing Address - Fax:423-844-4149
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-4290
Practice Address - Fax:423-844-4149
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist