Provider Demographics
NPI:1508140237
Name:BONNER, IMELDA AWUOR (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:AWUOR
Last Name:BONNER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:8705 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3909
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:480-405-8929
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1028675363LP0808X
AZ257911363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140149Medicaid