Provider Demographics
NPI:1316553746
Name:BONAZZA, JOE (RN)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:BONAZZA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 BIGLEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3904
Mailing Address - Country:US
Mailing Address - Phone:304-935-1069
Mailing Address - Fax:
Practice Address - Street 1:1508 BIGLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3904
Practice Address - Country:US
Practice Address - Phone:304-935-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73481163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management