Provider Demographics
NPI:1225403157
Name:DEJARDIN, BONNIE L (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:DEJARDIN
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:MS
Other - First Name:BONNIE
Other - Middle Name:LOU
Other - Last Name:LEDVINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-6050
Practice Address - Fax:920-433-6049
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6710-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner