Provider Demographics
NPI:1316713480
Name:BONVISSUTO, MARY (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BONVISSUTO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 9TH ST S APT 61A
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-2335
Mailing Address - Country:US
Mailing Address - Phone:301-802-2450
Mailing Address - Fax:
Practice Address - Street 1:11484 WASHINGTON PLZ W STE 300
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4342
Practice Address - Country:US
Practice Address - Phone:703-443-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188379363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care