Provider Demographics
NPI:1831609460
Name:BONVOLANTA, KATELYN ROSE (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ROSE
Last Name:BONVOLANTA
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MS
Other - First Name:KATELYN
Other - Middle Name:ROSE
Other - Last Name:KERR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:14729 BLUE SKIES ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4965
Mailing Address - Country:US
Mailing Address - Phone:734-788-5313
Mailing Address - Fax:
Practice Address - Street 1:414 UNION ST STE 100
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1989
Practice Address - Country:US
Practice Address - Phone:248-676-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292862363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health