Provider Demographics
NPI:1487106399
Name:JOHNSTON, BONNIE E (ANP)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:E
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 STUDT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7031
Mailing Address - Country:US
Mailing Address - Phone:314-989-1181
Mailing Address - Fax:314-989-1441
Practice Address - Street 1:11700 STUDT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7031
Practice Address - Country:US
Practice Address - Phone:314-989-1181
Practice Address - Fax:314-989-1441
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012016906363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1487106399Medicaid