Healthcare Provider Details

I. General information

NPI: 1700664851
Provider Name (Legal Business Name): SAMANTHA BONVEGNA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PENNSYLVANIA AVE
BEL AIR MD
21014-3660
US

IV. Provider business mailing address

838 N MARLYN AVE
ESSEX MD
21221-2122
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-6051
  • Fax:
Mailing address:
  • Phone: 410-830-9474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR225889
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95026943
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: