Provider Demographics
NPI:1770244295
Name:BONIFAS, ELIZABETH RENEE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:BONIFAS
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 1:10377 CHENOWITH RD
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-9058
Mailing Address - Country:US
Mailing Address - Phone:567-204-4208
Mailing Address - Fax:
Practice Address - Street 1:750 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-2969
Practice Address - Country:US
Practice Address - Phone:419-229-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.359828163W00000X
OHAPRN.CNP.0028654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse