Provider Demographics
NPI:1780103564
Name:LAWSON, BONITA MARIE
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:MARIE
Last Name:LAWSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 CARTER LN
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-5087
Mailing Address - Country:US
Mailing Address - Phone:423-526-7630
Mailing Address - Fax:
Practice Address - Street 1:351 CARTER LN
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-5087
Practice Address - Country:US
Practice Address - Phone:423-526-7630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily