Provider Demographics
NPI:1356373542
Name:PETERSON, BONNIE JANE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12935 HIGHWAY 231 431 N
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:AL
Mailing Address - Zip Code:35750-8631
Mailing Address - Country:US
Mailing Address - Phone:256-828-6766
Mailing Address - Fax:256-261-7877
Practice Address - Street 1:12935 HIGHWAY 231 431 N
Practice Address - Street 2:
Practice Address - City:HAZEL GREEN
Practice Address - State:AL
Practice Address - Zip Code:35750-8631
Practice Address - Country:US
Practice Address - Phone:256-828-6766
Practice Address - Fax:256-261-7877
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1057945363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19607Medicare UPIN