Provider Demographics
NPI:1396310504
Name:BOHNERT, BRIANNA NICOLE
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:NICOLE
Last Name:BOHNERT
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 1:9625 EMORY AVE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-4413
Mailing Address - Country:US
Mailing Address - Phone:276-245-8513
Mailing Address - Fax:
Practice Address - Street 1:628 LAKE ST NE
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-7919
Practice Address - Country:US
Practice Address - Phone:276-328-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001978103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst