Provider Demographics
NPI:1922713676
Name:BONILLA, JESSICA (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11459 JOHNS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3515
Mailing Address - Country:US
Mailing Address - Phone:770-497-1555
Mailing Address - Fax:
Practice Address - Street 1:11459 JOHNS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-3515
Practice Address - Country:US
Practice Address - Phone:770-497-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001609363LP2300X
IL209027137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care