Provider Demographics
NPI:1083495907
Name:BONILLA, JULIE L
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:BONILLA
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 1:1025 KOKOMO RD
Mailing Address - Street 2:
Mailing Address - City:HAIKU
Mailing Address - State:HI
Mailing Address - Zip Code:96708-5006
Mailing Address - Country:US
Mailing Address - Phone:215-600-9137
Mailing Address - Fax:
Practice Address - Street 1:1025 KOKOMO RD
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5006
Practice Address - Country:US
Practice Address - Phone:215-600-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency