Healthcare Provider Details

I. General information

NPI: 1740590454
Provider Name (Legal Business Name): BONNIE ROSE FOX PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S BANANA RIVER BLVD FL 2
COCOA BEACH FL
32931-5041
US

IV. Provider business mailing address

105 S BANANA RIVER BLVD FL 2
COCOA BEACH FL
32931-5041
US

V. Phone/Fax

Practice location:
  • Phone: 321-200-0346
  • Fax: 321-461-6667
Mailing address:
  • Phone: 321-200-0346
  • Fax: 321-461-6667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9105677
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: