Provider Demographics
NPI:1710264197
Name:BROSSARD, BONITA LORRAINE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:LORRAINE
Last Name:BROSSARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 DAHL DR
Mailing Address - Street 2:
Mailing Address - City:DE FOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-1553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:538 DAHL DR
Practice Address - Street 2:
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1553
Practice Address - Country:US
Practice Address - Phone:608-846-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25344-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse