Provider Demographics
NPI:1982337432
Name:LONNEBOTN, MYA AMALIE
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:AMALIE
Last Name:LONNEBOTN
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:S7708A LUCILLE LN
Mailing Address - Street 2:
Mailing Address - City:MERRIMAC
Mailing Address - State:WI
Mailing Address - Zip Code:53561-9567
Mailing Address - Country:US
Mailing Address - Phone:608-239-9073
Mailing Address - Fax:
Practice Address - Street 1:S7708A LUCILLE LN
Practice Address - Street 2:
Practice Address - City:MERRIMAC
Practice Address - State:WI
Practice Address - Zip Code:53561-9567
Practice Address - Country:US
Practice Address - Phone:608-239-9073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program