1619759065 NPI number — STEPHANIE MARIE BONILLA PADILLA

Table of content: STEPHANIE MARIE BONILLA PADILLA (NPI 1619759065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619759065 NPI number — STEPHANIE MARIE BONILLA PADILLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA PADILLA
Provider First Name:
STEPHANIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1619759065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1785 JOSE FERRER Y FERRER
Provider Second Line Business Mailing Address:
COND. MILLENIA PARK 1103
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-206-8074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PROFESSIONAL OFFICES PARK IV
Provider Second Line Business Practice Location Address:
997 SAN ROBERTO STREET
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-773-6508
Provider Business Practice Location Address Fax Number:
787-773-6544
Provider Enumeration Date:
10/19/2023

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: 390200000X , with the licence number:  PSI46121 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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