=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588495832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINA CASOLIBA BONACHE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2024
-----------------------------------------------------
Last Update Date | 08/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1152 GOODLETTE-FRANK RD N
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-778-7944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 SPRING LAKE CIR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34119-4678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-778-7944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11034594
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------