Provider Demographics
NPI:1417332123
Name:BONILLA, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
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 1:2107 AMSTERDAM AVE
Mailing Address - Street 2:APT 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2506
Mailing Address - Country:US
Mailing Address - Phone:917-736-0678
Mailing Address - Fax:718-528-3303
Practice Address - Street 1:2107 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2506
Practice Address - Country:US
Practice Address - Phone:917-736-0678
Practice Address - Fax:718-528-3303
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285118164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse