Provider Demographics
NPI:1851366694
Name:RYALL, BONITA ANNETTE (NP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:ANNETTE
Last Name:RYALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-690-3555
Mailing Address - Fax:
Practice Address - Street 1:731 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2349
Practice Address - Country:US
Practice Address - Phone:541-842-3771
Practice Address - Fax:541-842-3084
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75721363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics