Provider Demographics
NPI:1497929491
Name:BONGEL, KATHERINE ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANN
Last Name:BONGEL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:KARNOPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:133 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1920
Mailing Address - Country:US
Mailing Address - Phone:920-494-7551
Mailing Address - Fax:
Practice Address - Street 1:133 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1920
Practice Address - Country:US
Practice Address - Phone:920-494-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11076031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35042500Medicaid