Provider Demographics
NPI:1215045893
Name:DEGRAVE, BONNIE A (PTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:DEGRAVE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:A
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:
Practice Address - Street 1:1300 EGG HARBOR RD STE 108
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1284
Practice Address - Country:US
Practice Address - Phone:920-746-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40388200Medicaid
WI521358Medicare Oscar/Certification