Healthcare Provider Details

I. General information

NPI: 1003242207
Provider Name (Legal Business Name): YANISSE LEONOR BONILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N KENDALL DR STE 101E
MIAMI FL
33176-2166
US

IV. Provider business mailing address

15935 SW 90TH AVE
PALMETTO BAY FL
33157-1923
US

V. Phone/Fax

Practice location:
  • Phone: 305-667-8686
  • Fax: 305-667-8680
Mailing address:
  • Phone: 786-226-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9107385
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: