Provider Demographics
NPI:1982744777
Name:PACIELLO, BONNIE GAYLE (DOM)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:GAYLE
Last Name:PACIELLO
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:TOME
Mailing Address - State:NM
Mailing Address - Zip Code:87060-0553
Mailing Address - Country:US
Mailing Address - Phone:505-489-0067
Mailing Address - Fax:505-888-6701
Practice Address - Street 1:2240 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-6728
Practice Address - Fax:505-888-6701
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM700171100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator