Healthcare Provider Details

I. General information

NPI: 1689836918
Provider Name (Legal Business Name): CASEY RENEE BONAQUIST D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 1006
JACKSONVILLE FL
32207-8337
US

IV. Provider business mailing address

PO BOX 746647
ATLANTA GA
30374-6647
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-1795
  • Fax: 904-376-3478
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12248
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberOS12248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: