Provider Demographics
NPI:1700832979
Name:SCANLAN, BONNIE (NP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SCANLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 NIAGARA FALLS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:406 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SMETHPORT
Practice Address - State:PA
Practice Address - Zip Code:16749-1277
Practice Address - Country:US
Practice Address - Phone:814-887-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP000633B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027766530001Medicaid
PA1027766530003Medicaid
NY04217983Medicaid
PA1027766530002Medicaid