Provider Demographics
NPI:1346541166
Name:MIDTFJELL BONAGURA, SUSAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MIDTFJELL BONAGURA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NE 189TH LN
Mailing Address - Street 2:
Mailing Address - City:CITRA
Mailing Address - State:FL
Mailing Address - Zip Code:32113-2217
Mailing Address - Country:US
Mailing Address - Phone:352-595-4554
Mailing Address - Fax:
Practice Address - Street 1:520 NE 189TH LN
Practice Address - Street 2:
Practice Address - City:CITRA
Practice Address - State:FL
Practice Address - Zip Code:32113-2217
Practice Address - Country:US
Practice Address - Phone:352-595-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist