Provider Demographics
NPI:1750943346
Name:BONOMO, BRITTANY JORDAN
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:JORDAN
Last Name:BONOMO
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 1:2504 SLALOM DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-6300
Mailing Address - Country:US
Mailing Address - Phone:815-708-5627
Mailing Address - Fax:
Practice Address - Street 1:5236 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-7889
Practice Address - Country:US
Practice Address - Phone:469-952-5082
Practice Address - Fax:469-952-5043
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1318823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist