Provider Demographics
NPI:1639686363
Name:CLARK, BONITA JOAN (APRN)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:JOAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:JOAN
Other - Last Name:HOLLOMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1839 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-821-7213
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-821-7213
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily