Provider Demographics
NPI:1285190603
Name:BONELLI, DOMINIQUE GAETANO
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:GAETANO
Last Name:BONELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 STATE ROUTE 286
Mailing Address - Street 2:
Mailing Address - City:SALTSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15681-2276
Mailing Address - Country:US
Mailing Address - Phone:724-980-2467
Mailing Address - Fax:
Practice Address - Street 1:1933 STATE ROUTE 286
Practice Address - Street 2:
Practice Address - City:SALTSBURG
Practice Address - State:PA
Practice Address - Zip Code:15681-2276
Practice Address - Country:US
Practice Address - Phone:724-980-2467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer