Healthcare Provider Details

I. General information

NPI: 1922938489
Provider Name (Legal Business Name): AYESHA MICHELLE BONORA RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22601 N 19TH AVE STE 131
PHOENIX AZ
85027-1325
US

IV. Provider business mailing address

206 ROWLAND DR
WHITEWRIGHT TX
75491-6003
US

V. Phone/Fax

Practice location:
  • Phone: 866-762-4455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number624781
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: