Provider Demographics
NPI:1538616057
Name:BONILLA, MAGDALIZ (LND)
Entity type:Individual
Prefix:
First Name:MAGDALIZ
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE FLAMINGO
Mailing Address - Street 2:URB VILLAS DE LA PLAYA
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-6034
Mailing Address - Country:US
Mailing Address - Phone:787-409-2434
Mailing Address - Fax:
Practice Address - Street 1:155 CALLE FLAMINGO
Practice Address - Street 2:VILLAS DE LA PLAYA
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-6034
Practice Address - Country:US
Practice Address - Phone:787-409-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1952133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist