Provider Demographics
NPI:1295527596
Name:BOHANNON, KEITH ALLEN (APRN)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 SE G ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3740
Mailing Address - Country:US
Mailing Address - Phone:479-367-2552
Mailing Address - Fax:479-367-2584
Practice Address - Street 1:2707 SE G ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3740
Practice Address - Country:US
Practice Address - Phone:479-367-2552
Practice Address - Fax:479-367-2584
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR232468364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult