Provider Demographics
NPI:1568470375
Name:DANIEL, BONNIE E
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:E
Last Name:DANIEL
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:PO BOX 2255
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8159 NORTHUMBERLAND HWY
Practice Address - Street 2:
Practice Address - City:HEATHSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22473
Practice Address - Country:US
Practice Address - Phone:804-580-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024157970363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA500017495OtherRR MEDICARE
VA500000747Medicare PIN
VA500017495OtherRR MEDICARE