Provider Demographics
NPI:1669699617
Name:NILES, BONNIE LYNN (PTA)
Entity type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:LYNN
Last Name:NILES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 FIVE MILE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2835
Mailing Address - Country:US
Mailing Address - Phone:508-864-2853
Mailing Address - Fax:
Practice Address - Street 1:582 FIVE MILE RIVER RD
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2835
Practice Address - Country:US
Practice Address - Phone:508-864-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3132225200000X
FL20436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant