Provider Demographics
NPI:1700421336
Name:GOPEE-BONILLA, OMAWATIE SHELLY (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:OMAWATIE
Middle Name:SHELLY
Last Name:GOPEE-BONILLA
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:OMAWATIE
Other - Middle Name:
Other - Last Name:GOPEE-SANTANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, FNP-BC
Mailing Address - Street 1:289 HELENA AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-2118
Mailing Address - Country:US
Mailing Address - Phone:561-472-4701
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAND CONCOURSE FL 5
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:561-472-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF345067-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF345067-01OtherNEW YORK STATE OFFICE OF THE PROFESSIONS
MD2019039937OtherAMERICAN NURSES CREDENTIALING CENTER