Provider Demographics
NPI:1710750039
Name:BONNER, JOEVONNA
Entity type:Individual
Prefix:
First Name:JOEVONNA
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5614 N FRESNO ST STE 111
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-6034
Mailing Address - Country:US
Mailing Address - Phone:559-578-0306
Mailing Address - Fax:
Practice Address - Street 1:5614 N FRESNO ST STE 111
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6034
Practice Address - Country:US
Practice Address - Phone:559-578-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
CA374J00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No374U00000XNursing Service Related ProvidersHome Health Aide
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093588386Medicaid