Provider Demographics
NPI:1720484181
Name:BONNER, HOLLY ANN (NP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:BONNER
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 1:115 YANCEY PL
Mailing Address - Street 2:
Mailing Address - City:ARNOLDSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30619-1561
Mailing Address - Country:US
Mailing Address - Phone:856-630-4535
Mailing Address - Fax:
Practice Address - Street 1:892 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2724
Practice Address - Country:US
Practice Address - Phone:706-227-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA242454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN242454OtherSTATE LICENSE NUMBER
GA003154602AMedicaid