Healthcare Provider Details

I. General information

NPI: 1306165444
Provider Name (Legal Business Name): ROSE BONNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 GOVERNMENT CENTER PKWY STE 300
FAIRFAX VA
22035-1100
US

IV. Provider business mailing address

4309 MISSION CT
ALEXANDRIA VA
22310-3353
US

V. Phone/Fax

Practice location:
  • Phone: 703-324-3271
  • Fax: 703-322-1518
Mailing address:
  • Phone: 702-324-3271
  • Fax: 703-322-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001078473
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: