Healthcare Provider Details

I. General information

NPI: 1477210466
Provider Name (Legal Business Name): ANNEMARIE MIRANDA BONILLA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 02/14/2025
Certification Date: 01/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11460 W WASHINGTON BLVD
LOS ANGELES CA
90066-6030
US

IV. Provider business mailing address

16055 RAYEN ST
NORTH HILLS CA
91343-4848
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax:
Mailing address:
  • Phone: 415-328-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number301279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: