Provider Demographics
NPI:1497372239
Name:BONILLA, MONIQUE (LVN)
Entity Type:Individual
Prefix:MISS
First Name:MONIQUE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 30TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2644 30TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3051
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN699382164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse