Provider Demographics
NPI:1831101419
Name:WHALEN, BONNY LYN (MD)
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:LYN
Last Name:WHALEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BONNY
Other - Middle Name:LYN
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR.
Mailing Address - Street 2:DHMC - DEPT OF PEDIATRICS - NEWBORN NURSERY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-653-6081
Mailing Address - Fax:603-650-0910
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DHMC DEPT OF PEDIATRICS - NEWBORN NURSERY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-653-6081
Practice Address - Fax:603-650-0910
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12826208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3072323Medicaid
VT1011849Medicaid
NH3072323Medicaid
NHRE8412Medicare ID - Type Unspecified