Provider Demographics
NPI:1174842454
Name:EDGAR, BONNIE LOUISE I (OTR)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LOUISE
Last Name:EDGAR
Suffix:I
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 1:4412 VANDA DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4082
Mailing Address - Country:US
Mailing Address - Phone:318-245-2497
Mailing Address - Fax:
Practice Address - Street 1:3880 COLONIAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1062
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:239-351-2046
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10640225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1982Medicaid