Provider Demographics
NPI:1598156481
Name:JENZEN, BONITA J (APRN,CNP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:J
Last Name:JENZEN
Suffix:
Gender:F
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:BONITA
Other - Middle Name:
Other - Last Name:NORTHWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-642-2000
Mailing Address - Fax:
Practice Address - Street 1:275 11TH ST S
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4655
Practice Address - Country:US
Practice Address - Phone:701-642-2000
Practice Address - Fax:701-671-4106
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily