Provider Demographics
NPI:1396421970
Name:BONFANTE GONZALEZ, LIZZETTE VANESSA
Entity type:Individual
Prefix:
First Name:LIZZETTE
Middle Name:VANESSA
Last Name:BONFANTE GONZALEZ
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 1:200 E 131ST ST APT 7A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-3480
Mailing Address - Country:US
Mailing Address - Phone:646-703-3835
Mailing Address - Fax:
Practice Address - Street 1:200 E 131ST ST APT 7A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-3480
Practice Address - Country:US
Practice Address - Phone:646-703-3835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027987-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist