Provider Demographics
NPI:1679709554
Name:BONNER, TRACIE F (FNP)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:F
Last Name:BONNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:F
Other - Last Name:BONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:122 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-7046
Mailing Address - Country:US
Mailing Address - Phone:304-587-7301
Mailing Address - Fax:304-587-2464
Practice Address - Street 1:122 CENTER ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-7046
Practice Address - Country:US
Practice Address - Phone:304-587-7301
Practice Address - Fax:304-587-2464
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1679709554Medicaid
WV52119OtherSTATE NP LICENSE
WV1679709554Medicaid
WV52119OtherSTATE NP LICENSE