Healthcare Provider Details

I. General information

NPI: 1205370715
Provider Name (Legal Business Name): BONNIE ARCHULETA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CAVALIER BLVD SUITE 110
FLORENCE KY
41042-3950
US

IV. Provider business mailing address

75 CAVALIER BLVD SUITE 110
FLORENCE KY
41042-3950
US

V. Phone/Fax

Practice location:
  • Phone: 859-594-4510
  • Fax: 859-594-4519
Mailing address:
  • Phone: 859-594-4510
  • Fax: 859-594-4519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: