Provider Demographics
NPI:1457957367
Name:ABRAHAM, BONITA DENISE (FNP-C)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:DENISE
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1010 LIMESTONE AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-3117
Mailing Address - Country:US
Mailing Address - Phone:432-664-2128
Mailing Address - Fax:
Practice Address - Street 1:4222 WENDOVER AVE STE 400
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5924
Practice Address - Country:US
Practice Address - Phone:432-337-4782
Practice Address - Fax:432-653-4509
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty