Provider Demographics
NPI:1861067183
Name:KIDD, BONNIE A (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:KIDD
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 COURAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1555
Mailing Address - Country:US
Mailing Address - Phone:423-602-9797
Mailing Address - Fax:
Practice Address - Street 1:7345 COURAGE WAY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1555
Practice Address - Country:US
Practice Address - Phone:423-602-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2021031499363LP0808X
TN131825163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory