Healthcare Provider Details

I. General information

NPI: 1578492880
Provider Name (Legal Business Name): SUSAN KENNEY BONNEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 OAK ST
EXCELSIOR MN
55331-3035
US

IV. Provider business mailing address

1059 77TH ST W
VICTORIA MN
55386-2704
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-5685
  • Fax:
Mailing address:
  • Phone: 612-812-9842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number320766
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: