Provider Demographics
NPI:1205608882
Name:PICKETT, BONNIE DIANE (NP)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:DIANE
Last Name:PICKETT
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 1:1209 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAUPHIN ISLAND
Mailing Address - State:AL
Mailing Address - Zip Code:36528-4359
Mailing Address - Country:US
Mailing Address - Phone:251-214-6119
Mailing Address - Fax:
Practice Address - Street 1:12701 PADGETT SWITCH RD
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-4011
Practice Address - Country:US
Practice Address - Phone:251-824-2174
Practice Address - Fax:251-824-2286
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-158008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL513-27535OtherBCBS
AL345214Medicaid