Provider Demographics
NPI:1396598330
Name:SPECTRUM WELLNESS
Entity type:Organization
Organization Name:SPECTRUM WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:919-645-7138
Mailing Address - Street 1:2307 W CONE BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-4063
Mailing Address - Country:US
Mailing Address - Phone:919-645-7138
Mailing Address - Fax:
Practice Address - Street 1:2307 W CONE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-4063
Practice Address - Country:US
Practice Address - Phone:919-645-7138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)