Provider Demographics
NPI:1548683873
Name:AYCOCK, BONNIE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61979
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70161-1979
Mailing Address - Country:US
Mailing Address - Phone:225-342-7867
Mailing Address - Fax:225-342-0886
Practice Address - Street 1:3706 MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-3002
Practice Address - Country:US
Practice Address - Phone:504-394-3510
Practice Address - Fax:504-393-0437
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN114964163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health