Provider Demographics
NPI:1578809299
Name:BONELLA, CAROL LANCASTER (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LANCASTER
Last Name:BONELLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LYNN
Other - Last Name:LANCASTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:15200 BRANDYWINE DR SW
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-5817
Mailing Address - Country:US
Mailing Address - Phone:301-729-6588
Mailing Address - Fax:
Practice Address - Street 1:1 DIANE DR
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719
Practice Address - Country:US
Practice Address - Phone:304-298-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14785225100000X
WV2420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist