Provider Demographics
NPI:1730642745
Name:BONOMO, SARAH (NP-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:BONOMO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4655
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-4655
Mailing Address - Country:US
Mailing Address - Phone:818-679-7683
Mailing Address - Fax:
Practice Address - Street 1:11175 CAMPUS ST STE 21005
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-2608
Practice Address - Country:US
Practice Address - Phone:909-558-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010384363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner