1689767006 NPI number — MS. BONITA LYNNE ROBERTSON

Table of content: MS. BONITA LYNNE ROBERTSON (NPI 1689767006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689767006 NPI number — MS. BONITA LYNNE ROBERTSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
BONITA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689767006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2595 W COUNTY ROAD 300 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSTOWN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47220-9764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-358-5851
Provider Business Mailing Address Fax Number:
812-358-5851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2595 W COUNTY ROAD 300 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47220-9764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-358-5851
Provider Business Practice Location Address Fax Number:
812-358-5851
Provider Enumeration Date:
09/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 376K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)