Healthcare Provider Details

I. General information

NPI: 1982141933
Provider Name (Legal Business Name): BONNIE SUE REID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 CORONA RD STE 102
COLUMBIA MO
65203-2582
US

IV. Provider business mailing address

2101 CORONA RD STE 102
COLUMBIA MO
65203-2582
US

V. Phone/Fax

Practice location:
  • Phone: 573-234-1800
  • Fax: 573-234-1799
Mailing address:
  • Phone: 573-234-1800
  • Fax: 573-234-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1982141933
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2017002500
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: