Healthcare Provider Details

I. General information

NPI: 1619477114
Provider Name (Legal Business Name): BONNIE RAE CUMMINGS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 E MOORES PIKE
BLOOMINGTON IN
47401-7129
US

IV. Provider business mailing address

1070 N FOREST VIEW DR N
ELLETTSVILLE IN
47429-1082
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-7604
  • Fax:
Mailing address:
  • Phone: 765-212-4449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002272A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: