Provider Demographics
NPI:1851894109
Name:BONASSO, KRISTY JO
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:JO
Last Name:BONASSO
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 1:2276 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4922
Mailing Address - Country:US
Mailing Address - Phone:616-920-4192
Mailing Address - Fax:
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:616-920-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005302225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003878539Medicaid