Provider Demographics
NPI:1356391072
Name:BOTHNER, ILHAM (NP)
Entity type:Individual
Prefix:
First Name:ILHAM
Middle Name:
Last Name:BOTHNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:75 SPRINGFIELD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1832
Mailing Address - Country:US
Mailing Address - Phone:413-562-5173
Mailing Address - Fax:413-562-1716
Practice Address - Street 1:75 SPRINGFIELD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1832
Practice Address - Country:US
Practice Address - Phone:413-562-5173
Practice Address - Fax:413-562-1716
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA163675363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S65311Medicare UPIN