Healthcare Provider Details

I. General information

NPI: 1619308731
Provider Name (Legal Business Name): CAROLINE MARIE BONFANTI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2013
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WINNIPEG LN
LAWRENCE NJ
08648-4119
US

IV. Provider business mailing address

1625 SCHRADER BLVD
LOS ANGELES CA
90028-6213
US

V. Phone/Fax

Practice location:
  • Phone: 609-334-8096
  • Fax:
Mailing address:
  • Phone: 323-993-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95003726
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00456300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberF401818-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: