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General NPI Number Information
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NPI Number | 1114361219
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Entity Type | Individual
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Provider Name | MRS. JACLYN MARIE BONVENTRE
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Gender | Female
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Dates
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Enumeration Date | 04/20/2013
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Last Update Date | 09/05/2013
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Provider Practice Location Address
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Address Line | 18 CYNTHIA LN
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City | CENTER MORICHES
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State | NY
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Zip | 11934-2602
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Country | US
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Telephone | 631-909-2065
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Fax |
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Provider Business Mailing Address
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Address Line | 18 CYNTHIA LN
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City | CENTER MORICHES
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State | NY
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Zip | 11934-2602
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Country | US
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Telephone | 631-909-2065
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 484461041
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License Number State | NY
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