Healthcare Provider Details

I. General information

NPI: 1154195667
Provider Name (Legal Business Name): NICOLE LYNNE BONNO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE LYNNE COUGLER RN

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W BARNEY ST
GOUVERNEUR NY
13642-1040
US

IV. Provider business mailing address

4 COMMERCE LN
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-4440
  • Fax: 315-287-1858
Mailing address:
  • Phone: 315-386-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number751719
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355908
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: