Provider Demographics
NPI:1548339625
Name:WARDLE ROCHE, BONITA G (CRNP)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:G
Last Name:WARDLE ROCHE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:G
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:100 NEW SALEM RD
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8936
Mailing Address - Country:US
Mailing Address - Phone:724-437-0729
Mailing Address - Fax:724-437-2761
Practice Address - Street 1:100 NEW SALEM RD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8936
Practice Address - Country:US
Practice Address - Phone:724-437-0729
Practice Address - Fax:724-437-2761
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP000164F363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009799060001Medicaid
PA1009799060001Medicaid