Provider Demographics
NPI:1154627958
Name:WEGENAST, BONITA (LMP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:WEGENAST
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CORDOVA LN
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-8435
Mailing Address - Country:US
Mailing Address - Phone:306-370-5118
Mailing Address - Fax:
Practice Address - Street 1:580 GUARD ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-8044
Practice Address - Country:US
Practice Address - Phone:360-370-5118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist