Provider Demographics
NPI:1528170982
Name:GROESSL, BONNIE L (MSN)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:L
Last Name:GROESSL
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7296
Mailing Address - Country:US
Mailing Address - Phone:920-468-9315
Mailing Address - Fax:920-468-9791
Practice Address - Street 1:2149 VELP AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-5424
Practice Address - Country:US
Practice Address - Phone:920-434-8500
Practice Address - Fax:920-468-9791
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI79614163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0000XNursing Service ProvidersRegistered NursePain Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43845200Medicaid
WI43845200Medicaid
WI000007835Medicare ID - Type Unspecified