Provider Demographics
NPI:1841455342
Name:BONAVENA, KELLY (LAC, MSOM)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:BONAVENA
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 SHOREWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-2411
Mailing Address - Country:US
Mailing Address - Phone:203-824-2625
Mailing Address - Fax:206-420-7133
Practice Address - Street 1:102 N MERIDIAN
Practice Address - Street 2:UNIT 3A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-8630
Practice Address - Country:US
Practice Address - Phone:253-970-8256
Practice Address - Fax:206-420-7133
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 00003070171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist