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General NPI Number Information
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NPI Number | 1841455342
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Entity Type | Individual
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Provider Name | KELLY BONAVENA L.AC, MSOM
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Gender | Female
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Dates
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Enumeration Date | 07/23/2008
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Last Update Date | 07/28/2008
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Provider Practice Location Address
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Address Line | 102 N MERIDIAN UNIT 3A
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City | PUYALLUP
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State | WA
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Zip | 98371-8630
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Country | US
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Telephone | 253-970-8256
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Fax | 206-420-7133
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Provider Business Mailing Address
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Address Line | 12221 SHOREWOOD DR SW
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City | BURIEN
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State | WA
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Zip | 98146-2411
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Country | US
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Telephone | 203-824-2625
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Fax | 206-420-7133
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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 | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC 00003070
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License Number State | WA
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