Provider Demographics
NPI:1235984691
Name:SMITH, BONNIE ELLEN (PHLEBOTOMIST)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 PECK ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5517
Mailing Address - Country:US
Mailing Address - Phone:959-234-9007
Mailing Address - Fax:
Practice Address - Street 1:82 PECK ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5517
Practice Address - Country:US
Practice Address - Phone:959-234-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT09-1136Y99246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy