Provider Demographics
NPI:1427693654
Name:BONANNO, RYAN (ATC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BONANNO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2504
Mailing Address - Country:US
Mailing Address - Phone:706-272-6000
Mailing Address - Fax:
Practice Address - Street 1:1225 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2504
Practice Address - Country:US
Practice Address - Phone:706-272-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0012602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer