Provider Demographics
NPI:1588033658
Name:DESPAIN, BONITA LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:LYNN
Last Name:DESPAIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:BONITA
Other - Middle Name:LYNN
Other - Last Name:MCKEAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:422 7TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2619
Mailing Address - Country:US
Mailing Address - Phone:309-502-1408
Mailing Address - Fax:
Practice Address - Street 1:2201 KEENAN DR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2152
Practice Address - Country:US
Practice Address - Phone:218-283-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026804225100000X
IL160.005650225200000X
MNA2779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist