MEDICARE: BONNIE GREGORY CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	SP013165	PA

General Provider Information

NPI Number	:	1780010751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE GREGORY CRNP

Provider Business Mailing Address
First Line	:	PO BOX 1347
Second Line	:
City	:	KINGSTON
State	:	PA
Zip	:	18704-0347
Country	:	US
Telephone Number	:	570-288-8881
Fax Number	:	570-288-8065

Provider Business Practice Location Address
First Line	:	50 MOISEY DRIVE
Second Line	:	SUITE 202
City	:	HAZLETON
State	:	PA
Zip	:	18202-9297
Country	:	US
Telephone Number	:	570-501-6840
Fax Number	:	570-501-6916

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2013
Last Update Date	:	03/29/2014

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