1326548454 NPI number — JULIE BONHAM

Table of content: JULIE BONHAM (NPI 1326548454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326548454 NPI number — JULIE BONHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONHAM
Provider First Name:
JULIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326548454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8960 SPRINGBROOK DR NW STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-5810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-631-5653
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
803 3RD ST. SE
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
LITTLE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-315-6536
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 125J00000X , with the licence number:  DT95 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 467477400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com