Healthcare Provider Details

I. General information

NPI: 1356968903
Provider Name (Legal Business Name): DAIHANY MEJIA-BONILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 BUCKLAND DR
WATERBURY CT
06704-1116
US

IV. Provider business mailing address

50 BROOKSIDE RD
WATERBURY CT
06708-1402
US

V. Phone/Fax

Practice location:
  • Phone: 203-841-8961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: