Provider Demographics
NPI:1083748180
Name:RANDALL, BONNIE JEAN ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE JEAN
Middle Name:ELIZABETH
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 3 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3440
Mailing Address - Country:US
Mailing Address - Phone:616-363-3352
Mailing Address - Fax:
Practice Address - Street 1:2014 3 MILE RD NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3440
Practice Address - Country:US
Practice Address - Phone:616-363-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist