Provider Demographics
NPI:1710083357
Name:MOUNTAIN-BONNER, CHRISTY M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTY
Middle Name:M
Last Name:MOUNTAIN-BONNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHRISTY
Other - Middle Name:M
Other - Last Name:MOUNTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-0935
Mailing Address - Country:US
Mailing Address - Phone:478-412-6522
Mailing Address - Fax:478-412-6521
Practice Address - Street 1:601 FERNCREST DR STE B
Practice Address - Street 2:SUITE B
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1801
Practice Address - Country:US
Practice Address - Phone:478-552-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057222208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA996007389BMedicaid
GA057222OtherLICENSE NUMBER