Provider Demographics
NPI:1235305061
Name:BONANNO, ANDREA A
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:A
Last Name:BONANNO
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 1:9409B OLD BURKE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3127
Mailing Address - Country:US
Mailing Address - Phone:703-978-4200
Mailing Address - Fax:
Practice Address - Street 1:9409B OLD BURKE LAKE RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3127
Practice Address - Country:US
Practice Address - Phone:703-978-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily