MEDICARE: REBECCA ROSE BONNEVILLE NURSE PRACTITIONER

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	101YM0800X	Mental Health Counselor
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95010667	CA
3	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	22278	TN

General Provider Information

NPI Number	:	1821424375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA ROSE BONNEVILLE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	22704 VENTURA BLVD UNIT 115
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-1333
Country	:	US
Telephone Number	:	323-900-5091
Fax Number	:	323-538-6512

Provider Business Practice Location Address
First Line	:	22704 VENTURA BLVD UNIT 115
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-1333
Country	:	US
Telephone Number	:	323-900-5091
Fax Number	:	323-538-6512

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

Provider Enumeration Date	:	09/16/2013
Last Update Date	:	03/18/2026

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