Provider Demographics
NPI:1013681832
Name:BONNER, GABRIELLE RUTHANN (NP)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:RUTHANN
Last Name:BONNER
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 1:1965 S FREMONT AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2295
Mailing Address - Country:US
Mailing Address - Phone:417-820-3500
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE STE 350
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2295
Practice Address - Country:US
Practice Address - Phone:417-820-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021022266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily