Provider Demographics
NPI:1770733248
Name:BONNER, NICOLE R (CRNP-F)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:BONNER
Suffix:
Gender:F
Credentials:CRNP-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 KENT AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3798
Mailing Address - Country:US
Mailing Address - Phone:240-964-4887
Mailing Address - Fax:
Practice Address - Street 1:10701 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1457
Practice Address - Country:US
Practice Address - Phone:301-689-3229
Practice Address - Fax:301-689-1129
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR167886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216981ZFT6OtherPTAN