Provider Demographics
NPI:1184608986
Name:SUMMERS, BONNIE J (NP)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:J
Last Name:SUMMERS
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 1:6000 BOND AVE
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62207-2328
Mailing Address - Country:US
Mailing Address - Phone:618-332-2740
Mailing Address - Fax:618-332-8755
Practice Address - Street 1:6000 BOND AVE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62207-2328
Practice Address - Country:US
Practice Address - Phone:618-332-2740
Practice Address - Fax:618-337-6039
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAPN209000301OtherADV PRACTICE NURSE ID
ILRN041-127414OtherREGISTERED NURSE ID
P07153Medicare UPIN