Provider Demographics
NPI:1598220717
Name:MARION, PKANITA BONNER (NP)
Entity Type:Individual
Prefix:
First Name:PKANITA
Middle Name:BONNER
Last Name:MARION
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PKANITA
Other - Middle Name:
Other - Last Name:BONNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED
Mailing Address - Street 1:PO BOX 1395
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1395
Mailing Address - Country:US
Mailing Address - Phone:205-767-9992
Mailing Address - Fax:
Practice Address - Street 1:8425 MALL PARKWAY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038
Practice Address - Country:US
Practice Address - Phone:678-526-1014
Practice Address - Fax:678-526-1044
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF01191266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily