Healthcare Provider Details

I. General information

NPI: 1053950113
Provider Name (Legal Business Name): BONITA LOIS MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLLIN RAYE DR
DE QUEEN AR
71832-8048
US

IV. Provider business mailing address

358 BRIDGE CREEK RD
HORATIO AR
71842-9000
US

V. Phone/Fax

Practice location:
  • Phone: 870-584-1055
  • Fax:
Mailing address:
  • Phone: 870-784-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number123723
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: