MEDICARE: MRS. SANDRA J BONOM CFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SF0001X	Family Health Clinical Nurse Specialist	R100760	MS

General Provider Information

NPI Number	:	1285815548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA J BONOM CFNP

Provider Business Mailing Address
First Line	:	126 PINE RIDGE CIR
Second Line	:
City	:	BRANDON
State	:	MS
Zip	:	39047-7514
Country	:	US
Telephone Number	:	601-829-3734
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 PINE RIDGE CIR
Second Line	:
City	:	BRANDON
State	:	MS
Zip	:	39047-7514
Country	:	US
Telephone Number	:	601-829-3734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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