Healthcare Provider Details

I. General information

NPI: 1710456439
Provider Name (Legal Business Name): PHYLICIA JOANNE BONAVIDA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 12/06/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MILL ST
PRINCETON ME
04668-3344
US

IV. Provider business mailing address

136 MILL ST
PRINCETON ME
04668-3344
US

V. Phone/Fax

Practice location:
  • Phone: 207-796-5503
  • Fax:
Mailing address:
  • Phone: 207-297-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP181262
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: