Provider Demographics
NPI:1194869719
Name:HATALEY, BONNIE (PA)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:HATALEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:BAUERFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20 VALLEY VIEW CT
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2751
Mailing Address - Country:US
Mailing Address - Phone:203-507-2060
Mailing Address - Fax:
Practice Address - Street 1:20 VALLEY VIEW CT
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2751
Practice Address - Country:US
Practice Address - Phone:203-507-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000908363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002364Medicare ID - Type Unspecified
CTP03513Medicare UPIN