Provider Demographics
NPI:1760879738
Name:BONILLA, NELEEN TIBAYAN (CRNP)
Entity type:Individual
Prefix:
First Name:NELEEN
Middle Name:TIBAYAN
Last Name:BONILLA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NELEEN
Other - Middle Name:BONILLA
Other - Last Name:ORSAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 CATON AVENUE, MAILBOX 009
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229
Mailing Address - Country:US
Mailing Address - Phone:667-234-8912
Mailing Address - Fax:667-234-3556
Practice Address - Street 1:900 CATON AVENUE, MAILBOX 009
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:667-234-8912
Practice Address - Fax:667-234-3556
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177132363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner