Provider Demographics
NPI:1972566610
Name:HAGEN, BONNIE SK (LPN)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:SK
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7704 WESLEY RD.
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-3070
Mailing Address - Country:US
Mailing Address - Phone:815-639-9994
Mailing Address - Fax:815-639-9994
Practice Address - Street 1:7704 WESLEY RD.
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-3070
Practice Address - Country:US
Practice Address - Phone:815-639-9994
Practice Address - Fax:815-639-9994
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29454-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38235000Medicaid