Provider Demographics
NPI:1659347755
Name:BONNER, TERRY DUSTON
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:DUSTON
Last Name:BONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N BAY DR
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3026
Mailing Address - Country:US
Mailing Address - Phone:850-265-9973
Mailing Address - Fax:850-265-9973
Practice Address - Street 1:609 N BAY DR
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3026
Practice Address - Country:US
Practice Address - Phone:850-265-9973
Practice Address - Fax:850-265-9973
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2640982367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered