Provider Demographics
NPI:1316667645
Name:BONNER, KAITLYN ABIGAIL
Entity type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:ABIGAIL
Last Name:BONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20711 JUANITA LN
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-5325
Mailing Address - Country:US
Mailing Address - Phone:325-513-4288
Mailing Address - Fax:
Practice Address - Street 1:620 NW 5TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3947
Practice Address - Country:US
Practice Address - Phone:405-208-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK87631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical