Healthcare Provider Details

I. General information

NPI: 1124157060
Provider Name (Legal Business Name): MS. BONNIE CELESTE CREA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1988 HYLAN BLVD
STATEN ISLAND NY
10306-3526
US

IV. Provider business mailing address

159 GREAT KILLS RD
STATEN ISLAND NY
10308-2938
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-4300
  • Fax: 718-980-2636
Mailing address:
  • Phone: 718-667-4300
  • Fax: 718-980-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number030109089183903
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: