Provider Demographics
NPI:1891894101
Name:MOREHEAD, BONNIE LEE (CFNP)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:LEE
Last Name:MOREHEAD
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 1:204 DUVAL ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8207
Mailing Address - Country:US
Mailing Address - Phone:601-630-0132
Mailing Address - Fax:
Practice Address - Street 1:204 DUVAL ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8207
Practice Address - Country:US
Practice Address - Phone:601-630-0132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS99535Medicare UPIN