Provider Demographics
NPI:1184373839
Name:BONNER, MIRANDA (APRN, PMHNP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1100
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:1681 NORMAL DRIVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1041
Practice Address - Country:US
Practice Address - Phone:270-745-2273
Practice Address - Fax:270-745-2449
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018522363LP0808X
KY1117247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse