Healthcare Provider Details

I. General information

NPI: 1508444746
Provider Name (Legal Business Name): KARIN MICHELE BONANNO AOD, RADT-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NAPA VALLEJO HWY BLDG 253M1M2
NAPA CA
94558-6234
US

IV. Provider business mailing address

162 KHARTOUM ST
PACHECO CA
94553-6313
US

V. Phone/Fax

Practice location:
  • Phone: 707-255-8001
  • Fax:
Mailing address:
  • Phone: 925-812-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14571-RAC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: