Healthcare Provider Details

I. General information

NPI: 1700501830
Provider Name (Legal Business Name): HARLEY BONNIVILLE CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BULIFANTS BLVD
WILLIAMSBURG VA
23188-5747
US

IV. Provider business mailing address

2513 SPRING BRIDGE PL
SANDSTON VA
23150-4409
US

V. Phone/Fax

Practice location:
  • Phone: 757-564-7337
  • Fax:
Mailing address:
  • Phone: 804-971-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024184256
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: