Provider Demographics
NPI:1609207893
Name:BONNER, SHANDA
Entity Type:Individual
Prefix:
First Name:SHANDA
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 1:1504 PARK WAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1245
Mailing Address - Country:US
Mailing Address - Phone:314-449-4946
Mailing Address - Fax:314-449-4946
Practice Address - Street 1:1504 PARK WAY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1245
Practice Address - Country:US
Practice Address - Phone:314-449-4946
Practice Address - Fax:314-449-4946
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor