Provider Demographics
NPI:1366895120
Name:BONITATIBUS, RENEE (FNP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BONITATIBUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-3600
Mailing Address - Country:US
Mailing Address - Phone:518-365-1459
Mailing Address - Fax:
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily