Healthcare Provider Details

I. General information

NPI: 1659347755
Provider Name (Legal Business Name): MR. TERRY DUSTON BONNER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N BAY DR
LYNN HAVEN FL
32444-3026
US

IV. Provider business mailing address

609 N BAY DR
LYNN HAVEN FL
32444-3026
US

V. Phone/Fax

Practice location:
  • Phone: 850-265-9973
  • Fax: 850-265-9973
Mailing address:
  • Phone: 850-265-9973
  • Fax: 850-265-9973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2640982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: