Healthcare Provider Details

I. General information

NPI: 1528987203
Provider Name (Legal Business Name): STEPHANIE CAROLINA BONO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 MEDICAL CENTER BLVD STE 320
LAWRENCEVILLE GA
30046-7767
US

IV. Provider business mailing address

2200 MEDICAL CENTER BLVD STE 320
LAWRENCEVILLE GA
30046-7767
US

V. Phone/Fax

Practice location:
  • Phone: 770-292-3490
  • Fax: 678-701-9860
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14346
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: