Healthcare Provider Details

I. General information

NPI: 1265774517
Provider Name (Legal Business Name): ALICE BONNER RN, MS, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E 102ND ST
NEW YORK NY
10029-5204
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL BOX 3000
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-824-7228
  • Fax: 212-824-2311
Mailing address:
  • Phone: 212-987-3100
  • Fax: 212-731-5210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number657599
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: