Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 123723 | AR |
NPI | 1053950113 |
---|---|
Provider Name | Bonita Lois Martin |
First Address | Horatio, AR 71842-9000 |
Second Address | De Queen, AR 71832-8048 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/01/2020 |
Last Update Date | 11/02/2020 |