Healthcare Provider Details

I. General information

NPI: 1922108620
Provider Name (Legal Business Name): PATRICIA BUONVINO CRTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S MARION AVENUE LAKE CITY VA MEDICAL CENTER
LAKE CITY FL
32025-5808
US

IV. Provider business mailing address

403 10TH AVE NW
JASPER FL
32052-5845
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278G1100X
TaxonomyGeneral Care Certified Respiratory Therapist
License NumberTUC12
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: