Healthcare Provider Details

I. General information

NPI: 1679012330
Provider Name (Legal Business Name): BONITA E. PENN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BIDDLE AVE STE 100
NEWARK DE
19702-3967
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-7820
  • Fax: 302-836-7826
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0001008
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberLG-0001008
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: