Provider Demographics
NPI:1912116898
Name:BONOMO, VICTORIA (NP)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:BONOMO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BAYMENS CT
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2601
Mailing Address - Country:US
Mailing Address - Phone:631-244-9112
Mailing Address - Fax:631-563-6723
Practice Address - Street 1:45 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2502
Practice Address - Country:US
Practice Address - Phone:631-581-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300861363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health