Healthcare Provider Details

I. General information

NPI: 1811750078
Provider Name (Legal Business Name): SALLY DIANE BONHAM BSN, MSN, FNP, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY DIANE TAYLOR

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 HILLCREST DR STE 1
WACO TX
76708-3144
US

IV. Provider business mailing address

101 W LOUIS HENNA BLVD STE 300
AUSTIN TX
78728-1203
US

V. Phone/Fax

Practice location:
  • Phone: 254-741-6641
  • Fax: 257-453-7469
Mailing address:
  • Phone: 512-244-4272
  • Fax: 512-244-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number638280
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1182184
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: