Provider Demographics
NPI:1134536105
Name:BONAFEDE, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BONAFEDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:743 JEFFERSON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1635
Practice Address - Country:US
Practice Address - Phone:570-344-9997
Practice Address - Fax:570-344-3158
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily