Provider Demographics
NPI:1417611757
Name:BONNETTE, CHANELL R (PA-C)
Entity Type:Individual
Prefix:
First Name:CHANELL
Middle Name:R
Last Name:BONNETTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-3320
Mailing Address - Country:US
Mailing Address - Phone:803-378-2550
Mailing Address - Fax:
Practice Address - Street 1:1108 UNION ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-3320
Practice Address - Country:US
Practice Address - Phone:803-378-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1182636OtherNCCPA ID