Provider Demographics
NPI:1780432104
Name:ALPHONSO PONGNON, BONNY
Entity type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:ALPHONSO PONGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNY
Other - Middle Name:
Other - Last Name:PONGNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:139 PAYSON AVE
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034
Mailing Address - Country:US
Mailing Address - Phone:917-750-9348
Mailing Address - Fax:
Practice Address - Street 1:3512 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2804
Practice Address - Country:US
Practice Address - Phone:917-750-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2BAL1340409171400000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No171400000XOther Service ProvidersHealth & Wellness Coach