=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831714245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEA MACKENZIE BONINE MS, CGC (GENETIC COU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2020
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3931 LOUISIANA AVE S SUITE E315
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-993-5381
-----------------------------------------------------
Fax | 952-993-6539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3931 LOUISIANA AVE S SUITE E315
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-993-5381
-----------------------------------------------------
Fax | 952-993-6539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number | 1478-61
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number | 1408
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------