Provider Demographics
NPI:1801151188
Name:HAWTHORNE-BONANNO, KRISTA (KRISTA BONANNO)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:
Last Name:HAWTHORNE-BONANNO
Suffix:
Gender:F
Credentials:KRISTA BONANNO
Other - Prefix:MISS
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:HAWTHORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:114 CHANDLER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2925
Mailing Address - Country:US
Mailing Address - Phone:718-477-0351
Mailing Address - Fax:718-477-0351
Practice Address - Street 1:114 CHANDLER AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2925
Practice Address - Country:US
Practice Address - Phone:718-477-0351
Practice Address - Fax:718-477-0351
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173389021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist