Provider Demographics
NPI:1104173822
Name:CLARK, BONNIE J (LPN)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:J
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 CATON RD
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3741
Mailing Address - Country:US
Mailing Address - Phone:607-937-4385
Mailing Address - Fax:
Practice Address - Street 1:47 CATON RD
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3741
Practice Address - Country:US
Practice Address - Phone:607-937-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217212-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse