Provider Demographics
NPI:1821393430
Name:BONOMO, STACEY O'SHEA (LPN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:O'SHEA
Last Name:BONOMO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:O'SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:2073 OLYMPIC STREET
Practice Address - Street 2:#304
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3413
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:541-682-3551
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200530455LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse