Provider Demographics
NPI:1740590454
Name:FOX, BONNIE ROSE (PA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ROSE
Last Name:FOX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-574-9139
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:7125 MURRELL RD
Practice Address - Street 2:STE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7999
Practice Address - Country:US
Practice Address - Phone:321-757-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant