Provider Demographics
NPI:1093407694
Name:BONOVITCH, ALEXANDRA (DNP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:BONOVITCH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2058 BORGATA LOOP
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-5756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2058 BORGATA LOOP
Practice Address - Street 2:
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568-5756
Practice Address - Country:US
Practice Address - Phone:845-522-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC247546163WG0000X
SC27618363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice