Provider Demographics
NPI:1841680139
Name:BONNER, CHARLENE (FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
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 5777
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5777
Mailing Address - Country:US
Mailing Address - Phone:865-246-2104
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:1288 MILL CREEK CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-7820
Practice Address - Country:US
Practice Address - Phone:865-246-2104
Practice Address - Fax:865-246-2106
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345905363LF0000X
TXAP127855363LF0000X
TN19617363LF0000X
NY404725363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX447717ZMSYMedicare PIN