Provider Demographics
NPI:1205173549
Name:BONOMI, KELLI-ANNE
Entity type:Individual
Prefix:
First Name:KELLI-ANNE
Middle Name:
Last Name:BONOMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MCKINNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1808
Mailing Address - Country:US
Mailing Address - Phone:631-827-4337
Mailing Address - Fax:
Practice Address - Street 1:104 MAJESTIC DR
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-4935
Practice Address - Country:US
Practice Address - Phone:631-499-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator