Healthcare Provider Details

I. General information

NPI: 1548509250
Provider Name (Legal Business Name): BONNIE K SAMMONS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 MOCKSVILLE AVE
SALISBURY NC
28144-2705
US

IV. Provider business mailing address

611 MOCKSVILLE AVE
SALISBURY NC
28144-2705
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-7220
  • Fax: 704-647-0515
Mailing address:
  • Phone: 704-633-7220
  • Fax: 704-647-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5006100
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5006100
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number224018
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: