Healthcare Provider Details

I. General information

NPI: 1104980150
Provider Name (Legal Business Name): BONNIE J PARHAM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 AUSTIN ROAD
GUNPOWDER MD
21010
US

IV. Provider business mailing address

250 FOSTER KNOLL DR
JOPPA MD
21085-4704
US

V. Phone/Fax

Practice location:
  • Phone: 410-436-3001
  • Fax:
Mailing address:
  • Phone: 410-679-6647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP36500
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: