Provider Demographics
NPI:1811750078
Name:BONHAM, SALLY DIANE (BSN, MSN, FNP, IBCLC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:DIANE
Last Name:BONHAM
Suffix:
Gender:F
Credentials:BSN, MSN, FNP, IBCLC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:DIANE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:169 PRIVATE ROAD 1400 S
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:TX
Mailing Address - Zip Code:76671-3283
Mailing Address - Country:US
Mailing Address - Phone:817-648-1765
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-648-1765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX638280163WL0100X
TX1182184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant