Provider Demographics
NPI:1184942138
Name:BONELLO, BRIDGET ANTONIA (FPN)
Entity type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:ANTONIA
Last Name:BONELLO
Suffix:
Gender:F
Credentials:FPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30159 APPLE GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2736
Mailing Address - Country:US
Mailing Address - Phone:734-782-4095
Mailing Address - Fax:
Practice Address - Street 1:3333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-6284
Practice Address - Country:US
Practice Address - Phone:734-285-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195983363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health