Basic Information
| Provider Information | |||||||||
| NPI: | 1558570911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MADELINE LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE-PENTZ | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | MADELINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2001 GOLDORADO TRL | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956234521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126005366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1095 MARSHALL WAY STE 201 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956675722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303445470 | ||||||||
| FaxNumber: | 5307840323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | C173221 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.