Provider Demographics
NPI:1811311707
Name:BONAMER, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BONAMER
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 1:1014 W BARRY AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4310
Mailing Address - Country:US
Mailing Address - Phone:708-408-5214
Mailing Address - Fax:
Practice Address - Street 1:1014 W BARRY AVE
Practice Address - Street 2:APT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4310
Practice Address - Country:US
Practice Address - Phone:708-408-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960025672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer