Provider Demographics
NPI:1487875381
Name:BONNER, KELLY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 PRINCESS ANNE ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3300
Mailing Address - Country:US
Mailing Address - Phone:540-371-7118
Mailing Address - Fax:540-371-3248
Practice Address - Street 1:2216 PRINCESS ANNE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3300
Practice Address - Country:US
Practice Address - Phone:540-371-7118
Practice Address - Fax:540-371-3248
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical