Healthcare Provider Details

I. General information

NPI: 1679622146
Provider Name (Legal Business Name): MARY LYNN BONNETTE PHD, MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE 810
FORT MYERS FL
33901-5858
US

IV. Provider business mailing address

1920 VIRGINIA AVE 401
FORT MYERS FL
33901-3352
US

V. Phone/Fax

Practice location:
  • Phone: 239-337-4332
  • Fax: 239-334-3327
Mailing address:
  • Phone: 239-334-2677
  • Fax: 239-334-3327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN 1088062
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: