Provider Demographics
NPI:1689174492
Name:BASHAM, SONJA HEATHER
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:HEATHER
Last Name:BASHAM
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 1:9325 MEGAN CT
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1764
Mailing Address - Country:US
Mailing Address - Phone:330-998-0818
Mailing Address - Fax:
Practice Address - Street 1:9325 MEGAN CT
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1764
Practice Address - Country:US
Practice Address - Phone:330-998-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.408480163W00000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse