Provider Demographics
NPI:1508308883
Name:BONILLA, YVETTE
Entity Type:Individual
Prefix:
First Name:YVETTE
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 1:111 CENTRAL AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-1310
Mailing Address - Country:US
Mailing Address - Phone:401-632-5895
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:APT 1
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-1310
Practice Address - Country:US
Practice Address - Phone:401-632-5895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8631225200000X
RIPTA00855225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant