Provider Demographics
NPI:1487096376
Name:MARGARET HEFFERNAN BONIFACIO
Entity type:Organization
Organization Name:MARGARET HEFFERNAN BONIFACIO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:H
Authorized Official - Last Name:BONIFACIO
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, PMHNP-BC
Authorized Official - Phone:865-387-2904
Mailing Address - Street 1:304 GILBERT LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-3621
Mailing Address - Country:US
Mailing Address - Phone:865-387-2904
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:1758 HILLWOOD DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-2600
Practice Address - Country:US
Practice Address - Phone:865-387-2904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPM0000017637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty