Provider Demographics
NPI:1821532961
Name:BONILLA, BIANCA ANTOINETTE (224Z00000X)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:ANTOINETTE
Last Name:BONILLA
Suffix:
Gender:F
Credentials:224Z00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2894 WEST 8TH ST.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254
Mailing Address - Country:US
Mailing Address - Phone:904-325-8677
Mailing Address - Fax:
Practice Address - Street 1:36261 OKEFENOKEE DR
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7853
Practice Address - Country:US
Practice Address - Phone:912-496-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15458224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant