Basic Information
Provider Information | |||||||||
NPI: | 1114266541 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONOW | ||||||||
FirstName: | BROOKE | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635283 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452635283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8599127211 | ||||||||
FaxNumber: | 8596558981 | ||||||||
Practice Location | |||||||||
Address1: | 85 N GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | FORT THOMAS | ||||||||
State: | KY | ||||||||
PostalCode: | 410751793 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8599127211 | ||||||||
FaxNumber: | 8596556674 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2013 | ||||||||
LastUpdateDate: | 03/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007817 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 330723 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3007817 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 7100239690 | 05 | KY |   | MEDICAID | 0080524 | 05 | OH |   | MEDICAID | P01516729 | 01 | KY | RR MEDICARE | OTHER |