Provider Demographics
NPI:1902262231
Name:BONILLA, GLENN (NP-C)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10314 STONEHAM ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-8032
Mailing Address - Country:US
Mailing Address - Phone:661-444-6446
Mailing Address - Fax:
Practice Address - Street 1:2615 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2014
Practice Address - Country:US
Practice Address - Phone:661-395-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily