Provider Demographics
NPI:1346774577
Name:EVANS, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8613
Mailing Address - Country:US
Mailing Address - Phone:616-392-1873
Mailing Address - Fax:
Practice Address - Street 1:508 MONROE AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1063
Practice Address - Country:US
Practice Address - Phone:616-834-3526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704094585163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse