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NPI Code Detail

MEDICARE: ELYSSA BONNER

MEDICARE: ELYSSA BONNER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care CoordinatorPPS-0607528VA
2103TS0200XSchool PsychologistPPS-0607528VA

General Provider Information

NPI Number : 1629610092
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELYSSA BONNER
Provider Business Mailing Address
First Line : 8270 WILLOW OAKS CORPORATE DR
Second Line :
City : FAIRFAX
State : VA
Zip : 22031-4530
Country : US
Telephone Number : 571-423-4900
Fax Number :
Provider Business Practice Location Address
First Line : 8270 WILLOW OAKS CORPORATE DR
Second Line :
City : FAIRFAX
State : VA
Zip : 22031-4530
Country : US
Telephone Number : 571-423-4900
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2019
Last Update Date : 12/16/2025

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Directions to “ ELYSSA BONNER ” Practice Location

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