Healthcare Provider Details

I. General information

NPI: 1780733071
Provider Name (Legal Business Name): CLARA JOSEPHINE ACKER BONNEY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 HILLSIDE ROAD
CAMBRIDGE WI
53523
US

IV. Provider business mailing address

4252 POLARIS PARKWAY
JANESVILLE WI
53546
US

V. Phone/Fax

Practice location:
  • Phone: 608-423-3489
  • Fax:
Mailing address:
  • Phone: 608-868-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number21166031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: