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General NPI Number Information
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NPI Number | 1316667645
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Entity Type | Individual
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Provider Name | MRS. KAITLYN ABIGAIL BONNER
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Gender | Female
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Dates
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Enumeration Date | 08/29/2022
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Last Update Date | 08/29/2022
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Provider Practice Location Address
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Address Line | 620 NW 5TH ST STE D
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City | MOORE
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State | OK
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Zip | 73160-3947
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Country | US
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Telephone | 405-208-4469
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Fax |
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Provider Business Mailing Address
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Address Line | 20711 JUANITA LN
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City | TECUMSEH
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State | OK
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Zip | 74873-5325
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Country | US
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Telephone | 325-513-4288
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8763
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License Number State | OK
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