Basic Information
| Provider Information | |||||||||
| NPI: | 1912048950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERT | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERT | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | N4420 COUNTY ROAD C | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541627619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157588712 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | N6185 SCHOOL CREEK TRL | ||||||||
| Address2: | |||||||||
| City: | LUXEMBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542171035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208452128 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | WI | Y | Nursing Service Providers | Registered Nurse | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 3832100 | 05 | WI | MEDICAID |