Healthcare Provider Details

I. General information

NPI: 1548378201
Provider Name (Legal Business Name): BONITA L GILBERTSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. BONITA L MOISIO

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 WEST BARAGA AVENUE SUITE 30
MARQUETTE MI
49855
US

IV. Provider business mailing address

850 WEST BARAGA AVENUE SUITE 30
MARQUETTE MI
49855
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3914
  • Fax: 906-225-4583
Mailing address:
  • Phone: 906-225-3914
  • Fax: 906-225-4583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704201809
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704201809
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: