Provider Demographics
NPI:1457828964
Name:BONILLA, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
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 1:7865 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006-9745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7865 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:NY
Practice Address - Zip Code:14006-9745
Practice Address - Country:US
Practice Address - Phone:716-544-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY635520163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid