Provider Demographics
NPI:1043769821
Name:BONUS, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BONUS
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 1:7907 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1142
Mailing Address - Country:US
Mailing Address - Phone:347-494-5684
Mailing Address - Fax:347-494-5641
Practice Address - Street 1:7907 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1142
Practice Address - Country:US
Practice Address - Phone:347-494-5684
Practice Address - Fax:347-494-5641
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist