Provider Demographics
NPI:1619928413
Name:GILMORE, BONNY R (CRNA)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:R
Last Name:GILMORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:667 EASTLAND AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484
Practice Address - Country:US
Practice Address - Phone:330-841-4100
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN186940367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01188848OtherMEDICARE RAILROAD
OH0955980OtherMEDICAID
OHH139250OtherMEDICARE PTAN