Provider Demographics
NPI:1689336638
Name:BONNER, CRYSTAL L
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:BONNER
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 1:2546 KENTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-3353
Mailing Address - Country:US
Mailing Address - Phone:937-536-9481
Mailing Address - Fax:
Practice Address - Street 1:2546 KENTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-3353
Practice Address - Country:US
Practice Address - Phone:937-536-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1203610OtherDODD CERTIFICATION