Provider Demographics
NPI:1114808128
Name:BONILLA, CHARIZZ ANN DAGCUTA
Entity type:Individual
Prefix:
First Name:CHARIZZ ANN
Middle Name:DAGCUTA
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 1:1665 BRIDGEPORT
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-4116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1665 BRIDGEPORT
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-4116
Practice Address - Country:US
Practice Address - Phone:323-348-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036674363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily