Healthcare Provider Details

I. General information

NPI: 1831714245
Provider Name (Legal Business Name): SHEA MACKENZIE BONINE MS, CGC (GENETIC COU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHEA MACKENZIE BONINE

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 08/28/2024
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 LOUISIANA AVE S SUITE E315
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

3931 LOUISIANA AVE S SUITE E315
ST LOUIS PARK MN
55426
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5381
  • Fax: 952-993-6539
Mailing address:
  • Phone: 952-993-5381
  • Fax: 952-993-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number1478-61
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number1408
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: