Provider Demographics
NPI:1275310146
Name:BONIFACIO, MICHAEL G (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:BONIFACIO
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 1:2918 W LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1732
Mailing Address - Country:US
Mailing Address - Phone:773-817-2577
Mailing Address - Fax:
Practice Address - Street 1:2918 W LOGAN BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1732
Practice Address - Country:US
Practice Address - Phone:773-817-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028167363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health