Provider Demographics
NPI:1649327065
Name:BONURA, CAROL ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELIZABETH
Last Name:BONURA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NORTH COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-473-7171
Mailing Address - Fax:631-473-4605
Practice Address - Street 1:118 NORTH COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-473-7171
Practice Address - Fax:631-473-4605
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF390043363LP1700X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal