Provider Demographics
NPI:1023040458
Name:BONILLA, LILIA IVETTE (FNP)
Entity Type:Individual
Prefix:
First Name:LILIA
Middle Name:IVETTE
Last Name:BONILLA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2520
Mailing Address - Country:US
Mailing Address - Phone:219-413-5100
Mailing Address - Fax:219-465-9502
Practice Address - Street 1:1313 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3316
Practice Address - Country:US
Practice Address - Phone:219-398-9685
Practice Address - Fax:219-398-9695
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001263A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200848650Medicaid
71001263BOtherCSR