Healthcare Provider Details

I. General information

NPI: 1932648755
Provider Name (Legal Business Name): BONNIE MILTENBERGER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MICHIGAN AVE
LOGANSPORT IN
46947-1526
US

IV. Provider business mailing address

800 FULTON ST
LOGANSPORT IN
46947-1577
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-5151
  • Fax: 574-739-1414
Mailing address:
  • Phone: 574-722-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71006863A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: