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General NPI Number Information
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NPI Number | 1528036696
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Entity Type | Individual
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Provider Name | BONNIE L. GRUNDEL PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 369 N MAIN ST
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City | CRESTVIEW
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State | FL
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Zip | 32536-3541
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Country | US
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Telephone | 850-398-6963
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Fax | 850-398-8277
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Provider Business Mailing Address
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Address Line | 550 REDSTONE AVE W STE 490
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City | CRESTVIEW
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State | FL
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Zip | 32536-6457
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Country | US
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Telephone | 850-689-8321
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Fax | 850-689-8322
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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 | PA9101053
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License Number State | FL
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