Healthcare Provider Details

I. General information

NPI: 1174891337
Provider Name (Legal Business Name): BONNIE LYNN ANDERSON MS, CES, RCEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S MAIN ST
VIROQUA WI
54665-2059
US

IV. Provider business mailing address

507 S MAIN ST
VIROQUA WI
54665-2059
US

V. Phone/Fax

Practice location:
  • Phone: 608-637-4292
  • Fax: 608-638-5027
Mailing address:
  • Phone: 608-637-4292
  • Fax: 608-638-5027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: