Provider Demographics
NPI:1477059442
Name:BONOMO, LAUREN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:BONOMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33915 1ST WAY S
Mailing Address - Street 2:STE 130
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6396
Mailing Address - Country:US
Mailing Address - Phone:253-589-5776
Mailing Address - Fax:206-859-5776
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:#356524
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6524
Practice Address - Country:US
Practice Address - Phone:206-685-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61288641207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program