Provider Demographics
NPI:1700508496
Name:BONILLA, LIZZETTE (MASTERS PLUS 30)
Entity Type:Individual
Prefix:MS
First Name:LIZZETTE
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:MASTERS PLUS 30
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1026
Mailing Address - Country:US
Mailing Address - Phone:631-428-1590
Mailing Address - Fax:
Practice Address - Street 1:1014 GRAND BLVD STE 5
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5782
Practice Address - Country:US
Practice Address - Phone:631-243-1765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist