Provider Demographics
NPI:1619308731
Name:BONFANTI, CAROLINE MARIE (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:MARIE
Last Name:BONFANTI
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-993-7400
Mailing Address - Fax:
Practice Address - Street 1:24 WINNIPEG LN
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4119
Practice Address - Country:US
Practice Address - Phone:609-334-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-30
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401818-012084P0800X
NJ26NJ00456300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid