Provider Demographics
NPI:1811415672
Name:BONGERS, JULIE A
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:A
Last Name:BONGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17810 AMES COURT
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:507-838-5991
Mailing Address - Fax:
Practice Address - Street 1:17810 AMES CT
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-7933
Practice Address - Country:US
Practice Address - Phone:507-838-5991
Practice Address - Fax:507-838-5991
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN272601310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN272601OtherMN ADULT FOSTER CARE LICENSE NUMBER