1376261677 NPI number — MRS. PAMELA ANN BONILLA LPC-21205

Table of content: MRS. PAMELA ANN BONILLA LPC-21205 (NPI 1376261677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376261677 NPI number — MRS. PAMELA ANN BONILLA LPC-21205

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA
Provider First Name:
PAMELA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC-21205
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376261677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
651 N VAL VISTA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APACHE JUNCTION
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85119-8643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
148-081-8709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 N. DOBSON RD.
Provider Second Line Business Practice Location Address:
SUITE D3
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85014-8501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-420-7514
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC-21205 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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