Provider Demographics
NPI:1053385401
Name:SMITH, BONNIE GAYLE (FNP)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:GAYLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 EAST WEBER ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737
Mailing Address - Country:US
Mailing Address - Phone:225-644-4926
Mailing Address - Fax:
Practice Address - Street 1:200 CORPORATE BLVD
Practice Address - Street 2:SUITE #201
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3870
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN074262363LF0000X
LAAP03605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1158895Medicaid
LA1158895Medicaid
LA3A704CQ60Medicare PIN