Provider Demographics
NPI:1669788097
Name:JOHNSON, BONNIE LEE (PTA)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:7235 W APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1932
Practice Address - Country:US
Practice Address - Phone:414-815-6700
Practice Address - Fax:414-755-1434
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669788097Medicaid