Healthcare Provider Details

I. General information

NPI: 1144816174
Provider Name (Legal Business Name): JONATHAN MICHAEL BONIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 OLD SAINT AUGUSTINE RD
JACKSONVILLE FL
32258-2460
US

IV. Provider business mailing address

5717 SONORA PASS DR
SPARKS NV
89436-1813
US

V. Phone/Fax

Practice location:
  • Phone: 904-271-6000
  • Fax:
Mailing address:
  • Phone: 775-515-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9550700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: