MEDICARE: ILEANA MARIA BONANNO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1982355947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILEANA MARIA BONANNO

Provider Business Mailing Address
First Line	:	871 E BROADWAY APT 3
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-2322
Country	:	US
Telephone Number	:	984-289-7977
Fax Number	:

Provider Business Practice Location Address
First Line	:	871 E BROADWAY APT 3
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-2322
Country	:	US
Telephone Number	:	984-289-7977
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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Directions to “ ILEANA MARIA BONANNO ” Practice Location

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