Provider Demographics
NPI:1679857395
Name:KNUTSON, BONNIE SUE (PTA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-4204
Mailing Address - Country:US
Mailing Address - Phone:712-258-7344
Mailing Address - Fax:
Practice Address - Street 1:112 GAUL DR
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-8963
Practice Address - Country:US
Practice Address - Phone:712-943-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00340225200000X
SD0084225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant