Provider Demographics
NPI:1942846670
Name:HAITH, BONNI ELLEN
Entity Type:Individual
Prefix:
First Name:BONNI
Middle Name:ELLEN
Last Name:HAITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5439
Mailing Address - Country:US
Mailing Address - Phone:617-949-1132
Mailing Address - Fax:
Practice Address - Street 1:153 GEORGE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5439
Practice Address - Country:US
Practice Address - Phone:617-949-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN215174163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse