MEDICARE: KRISTIE DAWN BONNETT N.P

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	363LA2200X	Adult Health Nurse Practitioner	005001437	NC
2	363L00000X	Nurse Practitioner	5001437	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0050 01437	OTHER	NC	MEDICAL BOARD LICENSE
2	2005010216	OTHER	FL	CERTIFICATION

General Provider Information

NPI Number	:	1669401337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE DAWN BONNETT N.P

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	336-718-7080
Fax Number	:	336-718-9622

Provider Business Practice Location Address
First Line	:	1950 S HAWTHORNE RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-3912
Country	:	US
Telephone Number	:	336-718-8386
Fax Number	:	336-718-0290

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	10/25/2020

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