Provider Demographics
NPI:1225533854
Name:BONIFACIO, MYRNA MAE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:MAE
Last Name:BONIFACIO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MYRNA
Other - Middle Name:MAE
Other - Last Name:BONIFACIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4525 S SANDHILL RD STE 111
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5955
Mailing Address - Country:US
Mailing Address - Phone:702-353-5417
Mailing Address - Fax:
Practice Address - Street 1:4525 S SANDHILL RD STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5955
Practice Address - Country:US
Practice Address - Phone:702-353-5417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLPN12825164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid