Provider Demographics
NPI:1699078170
Name:BONNER, CARISSA ANN (PNP)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:BONNER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9249 W LAKE CITY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9602
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:989-422-4378
Practice Address - Street 1:9249 W LAKE CITY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9602
Practice Address - Country:US
Practice Address - Phone:989-422-5122
Practice Address - Fax:989-422-4378
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250132363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG27604075Medicare PIN