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General NPI Number Information
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NPI Number | 1164721221
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Entity Type | Individual
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Provider Name | CRYSTAL BONANNI PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/15/2011
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Last Update Date | 01/05/2024
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Provider Practice Location Address
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Address Line | 8333 N DAVIS HWY STE 601
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City | PENSACOLA
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State | FL
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Zip | 32514-6050
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Country | US
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Telephone | 850-497-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 3897 SAND DUNE CT
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City | DESTIN
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State | FL
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Zip | 32541-3209
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Country | US
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Telephone | 570-916-0106
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1967
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-05110
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | MA053074
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9109436
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License Number State | FL
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