Provider Demographics
NPI:1912234246
Name:GAULT, KAREN SUE BONAFEDE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:SUE BONAFEDE
Last Name:GAULT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1380 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4718
Mailing Address - Country:US
Mailing Address - Phone:503-234-6137
Mailing Address - Fax:503-594-1114
Practice Address - Street 1:530 1ST ST
Practice Address - Street 2:SUITE B-1
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3248
Practice Address - Country:US
Practice Address - Phone:503-804-0133
Practice Address - Fax:503-594-1114
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01193171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist