Healthcare Provider Details

I. General information

NPI: 1780599944
Provider Name (Legal Business Name): KIMBERLY BONILLA CASIANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 4 BOX 12118
YAUCO PR
00698-9695
US

IV. Provider business mailing address

HC 4 BOX 12118
YAUCO PR
00698-9695
US

V. Phone/Fax

Practice location:
  • Phone: 939-228-3352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2352
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: