Provider Demographics
NPI:1811750078
Name:BONHAM, SALLY DIANE (BSN, MSN, FNP, IBCLC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:DIANE
Last Name:BONHAM
Suffix:
Gender:F
Credentials:BSN, MSN, FNP, IBCLC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:DIANE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W LOUIS HENNA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-1203
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:512-244-2895
Practice Address - Street 1:3500 HILLCREST DR STE 1
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3144
Practice Address - Country:US
Practice Address - Phone:254-741-6641
Practice Address - Fax:257-453-7469
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX638280163WL0100X
TX1182184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant