Healthcare Provider Details

I. General information

NPI: 1023040458
Provider Name (Legal Business Name): LILIA IVETTE BONILLA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W CHICAGO AVE
EAST CHICAGO IN
46312-3316
US

IV. Provider business mailing address

2401 VALLEY DR
VALPARAISO IN
46383-2520
US

V. Phone/Fax

Practice location:
  • Phone: 219-398-9685
  • Fax: 219-398-9695
Mailing address:
  • Phone: 219-413-5100
  • Fax: 219-465-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001263A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: