Provider Demographics
NPI:1710049176
Name:ELLESTAD, BONNEY LOUISE (MED)
Entity Type:Individual
Prefix:MS
First Name:BONNEY
Middle Name:LOUISE
Last Name:ELLESTAD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SHOWERS DR # 7-104
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4740
Mailing Address - Country:US
Mailing Address - Phone:925-323-5536
Mailing Address - Fax:
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2300
Practice Address - Country:US
Practice Address - Phone:925-323-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other