Provider Demographics
NPI:1255333860
Name:O'REILLY, BONITA J (FNP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:J
Last Name:O'REILLY
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 1:5110 STONEY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3846
Mailing Address - Country:US
Mailing Address - Phone:269-372-3068
Mailing Address - Fax:
Practice Address - Street 1:8191 MOORSBRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7417
Practice Address - Country:US
Practice Address - Phone:269-312-8170
Practice Address - Fax:269-762-4785
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47-04-102421363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104545483Medicaid
MI104545456Medicaid
MI104545492Medicaid
MI104545465Medicaid
MIN25440004Medicare ID - Type Unspecified
MI104545492Medicaid