Provider Demographics
NPI:1679217806
Name:FISH, BONNIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ELIZABETH
Last Name:FISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 E STABLEGATE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5624
Mailing Address - Country:US
Mailing Address - Phone:407-719-9133
Mailing Address - Fax:
Practice Address - Street 1:355 BERKMANS LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5606
Practice Address - Country:US
Practice Address - Phone:864-657-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106192251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics