Provider Demographics
NPI:1477377265
Name:YESHURUN, BONITA C (RN)
Entity type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:C
Last Name:YESHURUN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PINE VALLEY RD STE 113
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4976
Mailing Address - Country:US
Mailing Address - Phone:678-996-5030
Mailing Address - Fax:678-996-5021
Practice Address - Street 1:688 BENTLEAF DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-1129
Practice Address - Country:US
Practice Address - Phone:678-860-4430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-09
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
GARN288265163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care