Provider Demographics
NPI:1053698308
Name:BONNER, LESLIE NICHOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICHOLE
Last Name:BONNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-4201
Mailing Address - Country:US
Mailing Address - Phone:205-786-4481
Mailing Address - Fax:205-786-6847
Practice Address - Street 1:668 LOMB AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1330
Practice Address - Country:US
Practice Address - Phone:205-786-4481
Practice Address - Fax:205-786-6847
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist