Provider Demographics
NPI:1437362613
Name:MURPHY, BONNIE (PTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MURPHY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:FATEMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:17725 W OBSERVATORY RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53146-3237
Mailing Address - Country:US
Mailing Address - Phone:414-510-0844
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-510-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI796-19208100000X, 225200000X
WI796-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437362613Medicaid