Provider Demographics
NPI:1053950113
Name:MARTIN, BONITA LOIS (NP)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:LOIS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 BRIDGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HORATIO
Mailing Address - State:AR
Mailing Address - Zip Code:71842-9000
Mailing Address - Country:US
Mailing Address - Phone:870-784-2729
Mailing Address - Fax:
Practice Address - Street 1:500 E COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-8048
Practice Address - Country:US
Practice Address - Phone:870-584-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123723363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology