Provider Demographics
NPI:1982411385
Name:BONNER, GWENDOLYN RENEE
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:RENEE
Last Name:BONNER
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 1:837 WOODLANE RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-1950
Mailing Address - Country:US
Mailing Address - Phone:609-534-6658
Mailing Address - Fax:
Practice Address - Street 1:837 WOODLANE RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER PARK
Practice Address - State:NJ
Practice Address - Zip Code:08010-1950
Practice Address - Country:US
Practice Address - Phone:609-534-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG043080001744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management