Provider Demographics
NPI:1730464652
Name:BONANNO, KATHY (DC)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:BONANNO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 DELTA RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5504
Mailing Address - Country:US
Mailing Address - Phone:516-398-0436
Mailing Address - Fax:516-804-8981
Practice Address - Street 1:15 DELTA RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5504
Practice Address - Country:US
Practice Address - Phone:516-398-0436
Practice Address - Fax:516-804-8981
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005300-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX005300-1OtherREGISTRATION CERTIFICATE