Provider Demographics
NPI:1811927205
Name:BONACCORSI, MARY T (APRN, DNP, FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BONACCORSI
Suffix:
Gender:F
Credentials:APRN, DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2970
Mailing Address - Country:US
Mailing Address - Phone:608-756-5555
Mailing Address - Fax:608-756-0174
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-756-0174
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004213363LF0000X
WI2628-033363LF0000X
WI2628-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811927205OtherBCBSWI
WI000054176-K400333954OtherWI MEDICARE
WI000084908-K400332994OtherWI MEDICARE
WI1811927205Medicaid
WIBONACMAROtherMERCYCARE INSURANCE
IL041305302Medicaid
406120105OtherPTAN