Provider Demographics
NPI:1528094406
Name:NIETO, BONITA R (CNM)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:R
Last Name:NIETO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:ROSE
Other - Last Name:PANZL-NIETO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2550 S PARKER RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1622
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2648172363L00000X
MD6201367A00000X
CO48620367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO019051OtherKAISER COMMERCIAL NUMBER
CO07486202Medicaid
AZ876401Medicaid
CO019051OtherKAISER COMMERCIAL NUMBER
AZ876401Medicaid
8EB018Medicare ID - Type Unspecified
COCOA105653Medicare PIN