Healthcare Provider Details

I. General information

NPI: 1467638205
Provider Name (Legal Business Name): BONNIE JEAN WEST L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 SAINT CLAIR AVE SUITE 100
SAINT PAUL MN
55105-2844
US

IV. Provider business mailing address

1337 SAINT CLAIR AVE SUITE 100
SAINT PAUL MN
55105-2844
US

V. Phone/Fax

Practice location:
  • Phone: 651-808-2191
  • Fax:
Mailing address:
  • Phone: 651-808-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1329
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: