Individual
FLORENCE BONUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2601 FERRY ST, LAFAYETTE, IN 47904-3061
(765) 448-8000
Mailing address
PO BOX 5545, LAFAYETTE, IN 47903-5545
(765) 448-8000
(765) 448-8085
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
05008917A
IN
225100000X
Physical Therapist
Primary
05008917A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000640820
ANTHEM PROVIDER NUMBER
IN
05
—
200967080
—
IN
Enumeration date
03/14/2007
Last updated
10/01/2010
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