Provider Demographics
NPI:1710266234
Name:BONANNO, ROBERT VINCENT (LPN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:VINCENT
Last Name:BONANNO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CHANEL DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3832
Mailing Address - Country:US
Mailing Address - Phone:631-905-7392
Mailing Address - Fax:
Practice Address - Street 1:108 CHANEL DR E
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3832
Practice Address - Country:US
Practice Address - Phone:631-905-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293365164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse