Provider Demographics
NPI:1295329712
Name:BOHANNA, SALLY Y
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:Y
Last Name:BOHANNA
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:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:SMITHERS
Mailing Address - State:WV
Mailing Address - Zip Code:25186-0746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 KANAWHA RD
Practice Address - Street 2:
Practice Address - City:CANNELTON
Practice Address - State:WV
Practice Address - Zip Code:25036-2503
Practice Address - Country:US
Practice Address - Phone:304-442-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker