Provider Demographics
NPI:1033531116
Name:MOSS, BONNIE SUE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:SUE
Last Name:MOSS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:4301 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6546
Practice Address - Country:US
Practice Address - Phone:813-870-4064
Practice Address - Fax:813-443-8146
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9289331363L00000X
FLARNP9289331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010919700Medicaid
FLHT364YMedicare PIN