Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | GA | GA |
Y | 207KA0200X | Allergist | GA | GA |
NPI | 1003369083 |
---|---|
Provider Name | Nancy Bonner |
First Address | Marietta, GA 30067-9305 |
Second Address | Marietta, GA 30067-9305 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2016 |
Last Update Date | 26/07/2016 |