Provider Demographics
NPI:1366427551
Name:BONNER, ALICE R (GNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:R
Last Name:BONNER
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FL ATTN: PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:630 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2038
Practice Address - Country:US
Practice Address - Phone:508-595-2000
Practice Address - Fax:508-853-7149
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
57691OtherFALLON COMMUNITY HEALTH
AA3457OtherHARVARD PILGRIM HEALTHCAR
NP0040OtherBLUE SHIELD HMO BLUE
NP0040OtherMEDICARE B
NP0040OtherBLUE SHIELD INDEMNITY
042472266008OtherTRICARE CHAMPUS
0700363OtherMEDICAID WELFARE
MA0700363Medicaid
8300310OtherEVERCARE
04247226OtherONE HEALTH PLAN
NP0040OtherBLUE CARE ELECT
NP0040OtherBLUE SHIELD INDEMNITY
AA3457OtherHARVARD PILGRIM HEALTHCAR