Provider Demographics
NPI:1033316526
Name:MACENKA, BONNIE (LVN)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MACENKA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CHEROKEE PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9579
Mailing Address - Country:US
Mailing Address - Phone:805-929-6348
Mailing Address - Fax:
Practice Address - Street 1:305 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5006
Practice Address - Country:US
Practice Address - Phone:805-348-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZN185428164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770665887Medicare UPIN