Provider Demographics
NPI:1669401337
Name:BONNETT, KRISTIE DAWN (NP)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:DAWN
Last Name:BONNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-7080
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:1950 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3912
Practice Address - Country:US
Practice Address - Phone:336-718-8386
Practice Address - Fax:336-718-0290
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC005001437363LA2200X
NC5001437363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0050 01437OtherMEDICAL BOARD LICENSE
FL2005010216OtherCERTIFICATION
NC2592668Medicare PIN