Healthcare Provider Details

I. General information

NPI: 1457710196
Provider Name (Legal Business Name): BONNIE GRACIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SW FRAZER AVE STE 282
PENDLETON OR
97801-0048
US

IV. Provider business mailing address

435 E NEWPORT AVE SUITE A
HERMISTON OR
97838-2487
US

V. Phone/Fax

Practice location:
  • Phone: 541-564-9390
  • Fax: 541-564-9389
Mailing address:
  • Phone: 541-564-9390
  • Fax: 541-564-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: