Healthcare Provider Details

I. General information

NPI: 1184608986
Provider Name (Legal Business Name): BONNIE J SUMMERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 BOND AVE
CENTREVILLE IL
62207-2328
US

IV. Provider business mailing address

6000 BOND AVE
CENTREVILLE IL
62207-2328
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-2740
  • Fax: 618-337-6039
Mailing address:
  • Phone: 618-332-2740
  • Fax: 618-332-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000301
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: