Provider Demographics
NPI:1487190963
Name:BONOMO, MARY ANN (BA)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:BONOMO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 W PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2611
Mailing Address - Country:US
Mailing Address - Phone:201-567-0500
Mailing Address - Fax:
Practice Address - Street 1:93 W PALISADE AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2611
Practice Address - Country:US
Practice Address - Phone:201-567-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator