Provider Demographics
NPI:1316086556
Name:HEBERLEIN, BONITA MARIE
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:MARIE
Last Name:HEBERLEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9117
Mailing Address - Country:US
Mailing Address - Phone:970-304-6420
Mailing Address - Fax:
Practice Address - Street 1:1555 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9117
Practice Address - Country:US
Practice Address - Phone:970-304-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29796163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29796OtherNURSING LICENSE
CO69057851Medicaid