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General NPI Number Information
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NPI Number | 1811750078
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Entity Type | Individual
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Provider Name | SALLY DIANE BONHAM BSN, MSN, FNP, IBCLC
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Gender | Female
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Dates
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Enumeration Date | 01/31/2024
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Last Update Date | 10/29/2025
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Provider Practice Location Address
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Address Line | 3500 HILLCREST DR STE 1
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City | WACO
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State | TX
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Zip | 76708-3144
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Country | US
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Telephone | 254-741-6641
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Fax | 257-453-7469
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Provider Business Mailing Address
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Address Line | 101 W LOUIS HENNA BLVD STE 300
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City | AUSTIN
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State | TX
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Zip | 78728-1203
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Country | US
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Telephone | 512-244-4272
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Fax | 512-244-2895
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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 | 163WL0100X
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Taxonomy Name | Lactation Consultant (Registered Nurse)
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License Number | 638280
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1182184
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License Number State | TX
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