Basic Information
Provider Information | |||||||||
NPI: | 1821112889 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONNICI | ||||||||
FirstName: | LYNEE | ||||||||
MiddleName: | DIANE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7281 BRANDON RD | ||||||||
Address2: |   | ||||||||
City: | SHINGLE SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 956829728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306771052 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2914A COLD SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | PLACERVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956674220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306421715 | ||||||||
FaxNumber: | 5306422064 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 03-041370 | CA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 03-041370 | 01 | CA | CAS | OTHER |