Provider Demographics
NPI:1821077066
Name:BONNER, KELLY (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5407
Mailing Address - Country:US
Mailing Address - Phone:715-717-7455
Mailing Address - Fax:
Practice Address - Street 1:2509 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2785
Practice Address - Country:US
Practice Address - Phone:715-717-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1732-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40449300Medicaid
WI0500 20195Medicare ID - Type Unspecified