Provider Demographics
NPI:1245537265
Name:BONNEVILLE, KELLY FIELD (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:FIELD
Last Name:BONNEVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:FIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:555 N DUKE ST FL 3
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-5945
Mailing Address - Fax:717-544-5944
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5945
Practice Address - Fax:717-544-5944
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054788363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical