Provider Demographics
NPI:1619961620
Name:AYCOCK, BONITA C (FNP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:C
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7200
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0200
Mailing Address - Country:US
Mailing Address - Phone:252-937-0200
Mailing Address - Fax:252-451-0056
Practice Address - Street 1:100 DODD ST
Practice Address - Street 2:
Practice Address - City:SPRING HOPE
Practice Address - State:NC
Practice Address - Zip Code:27882-9348
Practice Address - Country:US
Practice Address - Phone:252-478-5412
Practice Address - Fax:252-937-3100
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200892363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC500005810OtherRAILROAD MEDICARE
NC1619961620OtherNPI
NC58594OtherMEDICAL LICENSE
NC7000422Medicaid
NC363L00000XOtherTAXONOMY
NC363L00000XOtherTAXONOMY
NC7000422Medicaid
NC1619961620OtherNPI