Healthcare Provider Details

I. General information

NPI: 1922939545
Provider Name (Legal Business Name): TAYLOR BONACOLTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAYLOR GRACE

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18331 PINE NUT CT
LEHIGH ACRES FL
33972-7507
US

IV. Provider business mailing address

18331 PINE NUT CT
LEHIGH ACRES FL
33972-7507
US

V. Phone/Fax

Practice location:
  • Phone: 239-600-2816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number348684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: