Provider Demographics
NPI:1780733071
Name:ACKER BONNEY, CLARA JOSEPHINE (LPN)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:JOSEPHINE
Last Name:ACKER BONNEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4252 POLARIS PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546
Mailing Address - Country:US
Mailing Address - Phone:608-868-7582
Mailing Address - Fax:
Practice Address - Street 1:1608 HILLSIDE ROAD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:WI
Practice Address - Zip Code:53523
Practice Address - Country:US
Practice Address - Phone:608-423-3489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21166031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38352500Medicaid