Provider Demographics
NPI:1649447517
Name:TIBBITTS, BONNIE JEAN (OTR)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JEAN
Last Name:TIBBITTS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 TRUAX BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-1474
Mailing Address - Country:US
Mailing Address - Phone:715-552-1030
Mailing Address - Fax:
Practice Address - Street 1:4901 N CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-3869
Practice Address - Country:US
Practice Address - Phone:715-874-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1537026314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42058800Medicaid