Healthcare Provider Details

I. General information

NPI: 1194188268
Provider Name (Legal Business Name): BONNIE KITCHEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9485 MENTOR AVE STE 210
MENTOR OH
44060-8723
US

IV. Provider business mailing address

36000 EUCLID AVE # MSO
WILLOUGHBY OH
44094-4625
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-5571
  • Fax: 440-205-5744
Mailing address:
  • Phone: 440-953-6082
  • Fax: 440-953-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCOA.18995-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: