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General NPI Number Information
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NPI Number | 1477377265
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Entity Type | Individual
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Provider Name | BONITA C YESHURUN RN
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Gender | Female
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Dates
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Enumeration Date | 11/09/2024
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Last Update Date | 12/02/2024
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Provider Practice Location Address
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Address Line | 688 BENTLEAF DR
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City | DALLAS
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State | GA
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Zip | 30132-1129
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Country | US
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Telephone | 678-860-4430
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Fax |
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Provider Business Mailing Address
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Address Line | 80 PINE VALLEY RD STE 113
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City | HIRAM
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State | GA
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Zip | 30141-4976
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Country | US
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Telephone | 678-996-5030
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Fax | 678-996-5021
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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 | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163WA2000X
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Taxonomy Name | Administrator Registered Nurse
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License Number | RN288265
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License Number State | GA
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