Provider Demographics
NPI:1689286981
Name:BRACKENRIDGE, BONNIE IRENE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:IRENE
Last Name:BRACKENRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1024
Mailing Address - Country:US
Mailing Address - Phone:681-291-3034
Mailing Address - Fax:
Practice Address - Street 1:242 LOCUST ST
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1024
Practice Address - Country:US
Practice Address - Phone:681-291-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant