Provider Demographics
NPI:1942615026
Name:BONNIE, KATRINA L (NP)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:BONNIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:L
Other - Last Name:WAVLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2956
Mailing Address - Country:US
Mailing Address - Phone:315-342-0030
Mailing Address - Fax:315-216-6669
Practice Address - Street 1:300 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2956
Practice Address - Country:US
Practice Address - Phone:315-342-0030
Practice Address - Fax:315-342-0258
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03910592Medicaid
NY03910592Medicaid