Provider Demographics
NPI:1588856546
Name:BONILLA ALICEA, MARLENE (DPM)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:BONILLA ALICEA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:6625 LYNDALE AVE S STE 105
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2673
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006419-1213E00000X
MN1016213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist