Provider Demographics
NPI:1700501830
Name:BONNIVILLE, HARLEY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:
Last Name:BONNIVILLE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 SPRING BRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:SANDSTON
Mailing Address - State:VA
Mailing Address - Zip Code:23150-4409
Mailing Address - Country:US
Mailing Address - Phone:804-971-3420
Mailing Address - Fax:
Practice Address - Street 1:119 BULIFANTS BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5747
Practice Address - Country:US
Practice Address - Phone:757-564-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184256363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics