Healthcare Provider Details

I. General information

NPI: 1861943268
Provider Name (Legal Business Name): BONNIE SUE NICHOLS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7702 CENTRAL PARK DR
WACO TX
76712-6535
US

IV. Provider business mailing address

PO BOX 848476
DALLAS TX
75284-8476
US

V. Phone/Fax

Practice location:
  • Phone: 254-202-7710
  • Fax:
Mailing address:
  • Phone: 254-202-9330
  • Fax: 254-202-9349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP132326
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: