Provider Demographics
NPI:1154634723
Name:MACKEY, BONNIE THERESE (NP,PHD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:THERESE
Last Name:MACKEY
Suffix:
Gender:F
Credentials:NP,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12727 STATE ROUTE 90
Mailing Address - Street 2:
Mailing Address - City:LOCKE
Mailing Address - State:NY
Mailing Address - Zip Code:13092-4108
Mailing Address - Country:US
Mailing Address - Phone:315-246-8559
Mailing Address - Fax:561-892-2999
Practice Address - Street 1:3177 MERIDIAN WAY S APT 3
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-5055
Practice Address - Country:US
Practice Address - Phone:315-246-8559
Practice Address - Fax:561-892-2999
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305368363LA2200X
FL1503092363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner