Provider Demographics
NPI:1639210883
Name:BOHANNON, COLEEN
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:BOHANNON
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 1:8 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2919
Mailing Address - Country:US
Mailing Address - Phone:870-425-6901
Mailing Address - Fax:870-424-8703
Practice Address - Street 1:8 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2919
Practice Address - Country:US
Practice Address - Phone:870-425-6901
Practice Address - Fax:870-424-8703
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator