Provider Demographics
NPI:1568856771
Name:BONHAM, LISA DIANE (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:BONHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 S COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5519
Mailing Address - Country:US
Mailing Address - Phone:580-223-5070
Mailing Address - Fax:580-226-3569
Practice Address - Street 1:2530 S COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5519
Practice Address - Country:US
Practice Address - Phone:580-223-5070
Practice Address - Fax:580-226-3569
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0029404164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse