Provider Demographics
NPI:1578541223
Name:BONENCLARK, SUSAN E (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BONENCLARK
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 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8820
Mailing Address - Fax:352-674-8919
Practice Address - Street 1:5051 SE 110TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-3115
Practice Address - Country:US
Practice Address - Phone:352-674-1730
Practice Address - Fax:352-674-8930
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant