Provider Demographics
NPI:1962641449
Name:NORTHSEA, BONNIE LORETTA (MED)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LORETTA
Last Name:NORTHSEA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 NW 66TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4251
Mailing Address - Country:US
Mailing Address - Phone:352-514-1772
Mailing Address - Fax:
Practice Address - Street 1:4117 NW 66TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4251
Practice Address - Country:US
Practice Address - Phone:352-514-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2019-04-15
Deactivation Date:2012-02-23
Deactivation Code:
Reactivation Date:2014-07-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No252Y00000XAgenciesEarly Intervention Provider Agency