Provider Demographics
NPI:1598490336
Name:BONNER, LATUAVIA
Entity Type:Individual
Prefix:
First Name:LATUAVIA
Middle Name:
Last Name:BONNER
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 1:2303 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-2789
Mailing Address - Country:US
Mailing Address - Phone:469-883-9216
Mailing Address - Fax:
Practice Address - Street 1:2303 AVENUE H
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-2789
Practice Address - Country:US
Practice Address - Phone:469-883-9216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14785781744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management