Provider Demographics
NPI:1154540896
Name:BONOFIGLIO, GAIL LYNN (LAT)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:LYNN
Last Name:BONOFIGLIO
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15260 MARILYN DR
Mailing Address - Street 2:#4
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1073
Mailing Address - Country:US
Mailing Address - Phone:262-754-3450
Mailing Address - Fax:262-754-3451
Practice Address - Street 1:13825 W BURLEIGH RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3058
Practice Address - Country:US
Practice Address - Phone:262-754-3450
Practice Address - Fax:262-754-3451
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI273-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1891711008OtherOFFICE NPI