Provider Demographics
NPI:1679089312
Name:CANTU, BONNIE ASHLEY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ASHLEY
Last Name:CANTU
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 MARY LOU DR APT A
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-2763
Mailing Address - Country:US
Mailing Address - Phone:361-542-0604
Mailing Address - Fax:
Practice Address - Street 1:720 E DE LA ROSA ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-6734
Practice Address - Country:US
Practice Address - Phone:830-778-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT67422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT6742OtherTDLR
TX2000025146OtherBOARD OF CERTIFICATION FOR ATHLETIC TRAINERS