Provider Demographics
NPI:1730137423
Name:BURNETTE-VICK, BONNIE A (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:BURNETTE-VICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W MORRIS BLVD
Mailing Address - Street 2:STE. 400B
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-2283
Mailing Address - Country:US
Mailing Address - Phone:423-586-2410
Mailing Address - Fax:423-581-9692
Practice Address - Street 1:420 W MORRIS BLVD
Practice Address - Street 2:STE. 400B
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2283
Practice Address - Country:US
Practice Address - Phone:423-586-2410
Practice Address - Fax:423-581-9692
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3840100Medicaid
TN3840100Medicare PIN
G95506Medicare UPIN
TN3840100Medicaid