Provider Demographics
NPI:1043972953
Name:WALLACE, BONNY ANNE
Entity type:Individual
Prefix:
First Name:BONNY ANNE
Middle Name:
Last Name:WALLACE
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 1:1786 KINOOLE ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-5245
Mailing Address - Country:US
Mailing Address - Phone:808-959-5855
Mailing Address - Fax:
Practice Address - Street 1:167 AIPUNI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-1803
Practice Address - Country:US
Practice Address - Phone:808-959-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker