Provider Demographics
NPI:1760473672
Name:GOINES, BONNIE FAY (CFNP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:FAY
Last Name:GOINES
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 MATTHEW DR
Mailing Address - Street 2:STE D
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2565
Mailing Address - Country:US
Mailing Address - Phone:601-735-3918
Mailing Address - Fax:601-735-4227
Practice Address - Street 1:951 MATTHEW DR
Practice Address - Street 2:STE D
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2565
Practice Address - Country:US
Practice Address - Phone:601-735-3918
Practice Address - Fax:601-735-4227
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05082511Medicaid
Q46203Medicare UPIN
500001877Medicare ID - Type Unspecified