Basic Information
Provider Information | |||||||||
NPI: | 1235246372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVINE | ||||||||
FirstName: | BONNIE | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEYMOUR | ||||||||
OtherFirstName: | BONNIE | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2699 STIRLING RD STE 301302A | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333126517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549654922 | ||||||||
FaxNumber: | 9545151184 | ||||||||
Practice Location | |||||||||
Address1: | 2699 STIRLING RD STE 301302A | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333126517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549654922 | ||||||||
FaxNumber: | 9545151184 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 03/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 3079802 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
ID | Type | State | Issuer | Description | 300917300 | 05 | FL |   | MEDICAID |