Individual
MRS. BONNIE LEA MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
90 HOPE DR, MOUNTAIN HOME A F B, ID 83648-1057
(208) 828-7648
Mailing address
1085 JULIA ST, MOUNTAIN HOME, ID 83647-4687
(208) 599-0584
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
625810
TX
Other
Enumeration date
11/15/2005
Last updated
06/14/2010
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