Provider Demographics
NPI:1972676922
Name:BONNENFANT, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BONNENFANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:BONNEFANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1686 HACIENDA CT
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993-7704
Mailing Address - Country:US
Mailing Address - Phone:530-741-6245
Mailing Address - Fax:530-743-5044
Practice Address - Street 1:9980 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:CA
Practice Address - Zip Code:95953-2334
Practice Address - Country:US
Practice Address - Phone:530-695-0700
Practice Address - Fax:530-695-0701
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16633OtherLICENSE