Healthcare Provider Details

I. General information

NPI: 1235764630
Provider Name (Legal Business Name): CONRAD BONILLA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 CHESTNUT AVE
LONG BEACH CA
90813-1674
US

IV. Provider business mailing address

980 S LOS ROBLES AVE
PASADENA CA
91106-4362
US

V. Phone/Fax

Practice location:
  • Phone: 562-599-8444
  • Fax:
Mailing address:
  • Phone: 323-606-3189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95036333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: