Provider Demographics
NPI:1154905321
Name:GRUDE, BONNIE NADAENE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:NADAENE
Last Name:GRUDE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-7203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1707
Practice Address - Country:US
Practice Address - Phone:405-273-6383
Practice Address - Fax:405-214-1078
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK201526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily