Provider Demographics
NPI:1003234832
Name:BONNICHSEN, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BONNICHSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVERA MEDICAL GROUP PIERRE - HELMSLEY CENTER
Mailing Address - Street 2:801 E SIOUX AVE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5217
Mailing Address - Fax:
Practice Address - Street 1:AVERA MEDICAL GROUP PIERRE - HELMSLEY CENTER
Practice Address - Street 2:801 E SIOUX AVE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10974207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology