1598220717 NPI number — PKANITA BONNER MARION NP

Table of content: PKANITA BONNER MARION NP (NPI 1598220717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598220717 NPI number — PKANITA BONNER MARION NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARION
Provider First Name:
PKANITA
Provider Middle Name:
BONNER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BONNER
Provider Other First Name:
PKANITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
REGISTERED
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598220717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1395
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30058-1395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-767-9992
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8425 MALL PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-526-1014
Provider Business Practice Location Address Fax Number:
678-526-1044
Provider Enumeration Date:
02/01/2019

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: 363LF0000X , with the licence number:  F01191266 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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