Provider Demographics
NPI:1922714005
Name:BONZO, MIKAYLA (IECE)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:BONZO
Suffix:
Gender:F
Credentials:IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:WURTLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41144-6238
Mailing Address - Country:US
Mailing Address - Phone:606-694-2362
Mailing Address - Fax:
Practice Address - Street 1:58 VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:WURTLAND
Practice Address - State:KY
Practice Address - Zip Code:41144-6238
Practice Address - Country:US
Practice Address - Phone:606-694-2362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist