Provider Demographics
NPI:1255460952
Name:BONNEVILLE, NOAH SETH (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:NOAH
Middle Name:SETH
Last Name:BONNEVILLE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 OLD IRONSIDES DR STE 304
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-1846
Mailing Address - Country:US
Mailing Address - Phone:323-205-7088
Mailing Address - Fax:
Practice Address - Street 1:4633 OLD IRONSIDES DR STE 304
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-1846
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA95021678363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner