Provider Demographics
NPI:1396878880
Name:QUALE, BONITA R
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:R
Last Name:QUALE
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 1:47710 INTERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9694
Mailing Address - Country:US
Mailing Address - Phone:907-776-8684
Mailing Address - Fax:907-776-8805
Practice Address - Street 1:47710 INTERLAKE DR
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-9694
Practice Address - Country:US
Practice Address - Phone:907-776-8684
Practice Address - Fax:907-776-8805
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100608310400000X
AK224310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL 3719Medicaid
AKRL4771Medicaid