MEDICARE: RAMON BONIFACIO APN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209.033588	IL

General Provider Information

NPI Number	:	1578430773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAMON BONIFACIO APN, PMHNP-BC

Provider Business Mailing Address
First Line	:	2918 W LOGAN BLVD UNIT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1732
Country	:	US
Telephone Number	:	773-810-9120
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 N STATE ST FL 15
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-3206
Country	:	US
Telephone Number	:	312-600-3991
Fax Number	:	630-473-2232

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2025
Last Update Date	:	01/20/2026

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