Healthcare Provider Details

I. General information

NPI: 1598510596
Provider Name (Legal Business Name): MIGUEL BONOAN MSN, RN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WESTWOOD PLZ
LOS ANGELES CA
90095-4103
US

IV. Provider business mailing address

7321 PASO ROBLES AVE
LAKE BALBOA CA
91406-2613
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-4073
  • Fax:
Mailing address:
  • Phone: 818-800-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN95265374
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License NumberRN95265374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: