Healthcare Provider Details

I. General information

NPI: 1295186302
Provider Name (Legal Business Name): MELINDA FLOCKE BONNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42205 VETERANS AVE
HAMMOND LA
70403
US

IV. Provider business mailing address

42205 VETERANS AVE
HAMMOND LA
70403-1424
US

V. Phone/Fax

Practice location:
  • Phone: 985-375-9979
  • Fax:
Mailing address:
  • Phone: 985-375-9979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number302858
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: