Provider Demographics
NPI:1831714245
Name:BONINE, SHEA MACKENZIE (MS, CGC (GENETIC COU)
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:MACKENZIE
Last Name:BONINE
Suffix:
Gender:F
Credentials:MS, CGC (GENETIC COU
Other - Prefix:
Other - First Name:SHEA
Other - Middle Name:MACKENZIE
Other - Last Name:BONINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3931 LOUISIANA AVE S
Mailing Address - Street 2:SUITE E315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:952-993-5381
Mailing Address - Fax:952-993-6539
Practice Address - Street 1:3931 LOUISIANA AVE S
Practice Address - Street 2:SUITE E315
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-5381
Practice Address - Fax:952-993-6539
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
WI1478-61170300000X
MN1408170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS