Provider Demographics
NPI:1336624485
Name:BONDS, NICOLE GRANT
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRANT
Last Name:BONDS
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 1:303 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5229
Mailing Address - Country:US
Mailing Address - Phone:912-283-0777
Mailing Address - Fax:
Practice Address - Street 1:106 SHOPPERS WAY STE 112
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-0522
Practice Address - Country:US
Practice Address - Phone:912-554-3805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP010180Medicaid