Provider Demographics
NPI:1578039897
Name:MYERS, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MYERS
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 1:18120 JOAN AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-8608
Mailing Address - Country:US
Mailing Address - Phone:651-214-0812
Mailing Address - Fax:
Practice Address - Street 1:18120 JOAN AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-8608
Practice Address - Country:US
Practice Address - Phone:651-214-0812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency