Healthcare Provider Details

I. General information

NPI: 1760188726
Provider Name (Legal Business Name): GABRIELLA BONFANTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3039 JOHNSON ST
HOLLYWOOD FL
33021-5536
US

IV. Provider business mailing address

4765 SW 148TH AVE STE 404
DAVIE FL
33330-2128
US

V. Phone/Fax

Practice location:
  • Phone: 954-900-1497
  • Fax:
Mailing address:
  • Phone: 954-374-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117179
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberNA
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: