Provider Demographics
NPI:1912048950
Name:HERT, BONNIE L
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:HERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:L
Other - Last Name:HERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:N4420 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-7619
Mailing Address - Country:US
Mailing Address - Phone:715-758-8712
Mailing Address - Fax:
Practice Address - Street 1:N6185 SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1035
Practice Address - Country:US
Practice Address - Phone:920-845-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3832100Medicaid