Provider Demographics
NPI:1821424375
Name:BONNEVILLE, REBECCA ROSE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ROSE
Last Name:BONNEVILLE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 SAN VICENTE BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5448
Mailing Address - Country:US
Mailing Address - Phone:323-870-6161
Mailing Address - Fax:510-653-6475
Practice Address - Street 1:6310 SAN VICENTE BLVD STE 360
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5448
Practice Address - Country:US
Practice Address - Phone:323-870-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
101YM0800X
TN22278363LP0808X
CA1821424375363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health