Provider Demographics
NPI:1487100566
Name:BONHAM, DEAXTRA (WHNP)
Entity type:Individual
Prefix:MRS
First Name:DEAXTRA
Middle Name:
Last Name:BONHAM
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:DEAXTRA
Other - Middle Name:
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:550 PEACHTREE ST NE STE 1275
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2240
Mailing Address - Country:US
Mailing Address - Phone:404-872-3121
Mailing Address - Fax:404-872-3119
Practice Address - Street 1:550 PEACHTREE ST NE STE 1275
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2240
Practice Address - Country:US
Practice Address - Phone:404-872-3121
Practice Address - Fax:404-872-3119
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173381363LW0102X
NC5009520363LW0102X
GAGAA-NP000016363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003254615Medicaid