Provider Demographics
NPI:1992705016
Name:BONOMO, CARRIE ANN (MD)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ANN
Last Name:BONOMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:204 SERIO BLVD
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334
Mailing Address - Country:US
Mailing Address - Phone:318-757-8010
Mailing Address - Fax:318-757-9501
Practice Address - Street 1:204 SERIO BLVD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334
Practice Address - Country:US
Practice Address - Phone:318-757-8010
Practice Address - Fax:318-757-9501
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026732208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1160059Medicaid