Provider Demographics
NPI:1518964972
Name:MASK, BONNIE JOYCE (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JOYCE
Last Name:MASK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:JOYCE
Other - Last Name:BAGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:300 OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3117
Practice Address - Country:US
Practice Address - Phone:662-534-8166
Practice Address - Fax:662-534-8132
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR700622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119803Medicaid
R76892Medicare UPIN