Provider Demographics
NPI:1013341445
Name:BONENFANT, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BONENFANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1407
Mailing Address - Country:US
Mailing Address - Phone:207-834-4117
Mailing Address - Fax:207-834-3829
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1407
Practice Address - Country:US
Practice Address - Phone:207-834-4117
Practice Address - Fax:207-834-3829
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist