Provider Demographics
NPI:1396518502
Name:WOODWARD, BONITA MARIE
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:MARIE
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BALLOUVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-1201
Mailing Address - Country:US
Mailing Address - Phone:860-481-1264
Mailing Address - Fax:
Practice Address - Street 1:44 BALLOUVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-1201
Practice Address - Country:US
Practice Address - Phone:860-481-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
568946544OtherBCBS
DC236Medicaid
5874OtherHEALTH PARTNERS