Healthcare Provider Details

I. General information

NPI: 1598996241
Provider Name (Legal Business Name): STEPHANIE BONNEAU CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

69 MASHAPAUG RD
STURBRIDGE MA
01566-1407
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-6030
  • Fax:
Mailing address:
  • Phone: 717-515-8316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2258078
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: