Healthcare Provider Details

I. General information

NPI: 1144574757
Provider Name (Legal Business Name): BONNIE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2012
Last Update Date: 11/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4034 N 18TH ST 3535 N 50TH STREET
MILWAUKEE WI
53209-6802
US

IV. Provider business mailing address

4034 N 18TH ST
MILWAUKEE WI
53209-6802
US

V. Phone/Fax

Practice location:
  • Phone: 414-449-5814
  • Fax: 414-445-6977
Mailing address:
  • Phone: 414-449-5814
  • Fax: 414-445-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: