Provider Demographics
NPI:1073653226
Name:BONANO, EVELYN JEAN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:JEAN
Last Name:BONANO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-1701
Mailing Address - Country:US
Mailing Address - Phone:919-847-9350
Mailing Address - Fax:
Practice Address - Street 1:3500 REGENCY PKWY
Practice Address - Street 2:120
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-8519
Practice Address - Country:US
Practice Address - Phone:919-465-3966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2249225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134TOtherBCBS OF NC