Provider Demographics
NPI:1427786581
Name:BONISCAVAGE, MICHELLE LYNN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BONISCAVAGE
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 1:8 BROOKHILL SQUARE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SUGARLOAF
Mailing Address - State:PA
Mailing Address - Zip Code:18249-1010
Mailing Address - Country:US
Mailing Address - Phone:570-459-0029
Mailing Address - Fax:570-454-5757
Practice Address - Street 1:2650 WESTVIEW DR. #H
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1187
Practice Address - Country:US
Practice Address - Phone:610-750-9426
Practice Address - Fax:484-282-7430
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily