Provider Demographics
NPI:1922854231
Name:BONILLA, AUDRY
Entity type:Individual
Prefix:
First Name:AUDRY
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 KEYSER MILL RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-8354
Mailing Address - Country:US
Mailing Address - Phone:815-557-3004
Mailing Address - Fax:
Practice Address - Street 1:5140 KEYSER MILL RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-8354
Practice Address - Country:US
Practice Address - Phone:815-557-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA97730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist