Healthcare Provider Details

I. General information

NPI: 1386026557
Provider Name (Legal Business Name): BONNIE RENEE PATRICK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 TOWNSHIP ROAD 508 E
SOUTH POINT OH
45680-7276
US

IV. Provider business mailing address

305 N 5TH ST
IRONTON OH
45638-1578
US

V. Phone/Fax

Practice location:
  • Phone: 740-377-2712
  • Fax: 740-377-2588
Mailing address:
  • Phone: 740-532-3534
  • Fax: 740-532-4859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009364
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number019848
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: