Healthcare Provider Details

I. General information

NPI: 1215383385
Provider Name (Legal Business Name): JENNIFER BONNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 N NORTHHILLS BLVD
FAYETTEVILLE AR
72703-4424
US

IV. Provider business mailing address

210 W PARK ST
LINCOLN AR
72744-8718
US

V. Phone/Fax

Practice location:
  • Phone: 479-409-3045
  • Fax:
Mailing address:
  • Phone: 479-409-3045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License NumberR070615
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: