Provider Demographics
NPI:1821679242
Name:BONAM, NICHELLE
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:BONAM
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 1:17114 PASSAGE AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-5561
Mailing Address - Country:US
Mailing Address - Phone:562-619-0483
Mailing Address - Fax:
Practice Address - Street 1:17114 PASSAGE AVE APT 108
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5561
Practice Address - Country:US
Practice Address - Phone:562-619-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA708047164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAOtherNA