Provider Demographics
NPI:1619309580
Name:BONAR, NICKIE (LMT)
Entity Type:Individual
Prefix:
First Name:NICKIE
Middle Name:
Last Name:BONAR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11698 MEREDITH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2226
Mailing Address - Country:US
Mailing Address - Phone:402-237-9110
Mailing Address - Fax:
Practice Address - Street 1:1710 N 144TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4715
Practice Address - Country:US
Practice Address - Phone:402-237-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3033172M00000X, 225700000X
173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist
No173C00000XOther Service ProvidersReflexologist