Provider Demographics
NPI:1578817854
Name:PERKINS/CRACKEL, BONNIE LOU
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:LOU
Last Name:PERKINS/CRACKEL
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 1:116 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663-9124
Mailing Address - Country:US
Mailing Address - Phone:231-824-6383
Mailing Address - Fax:231-824-6939
Practice Address - Street 1:116 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:MANTON
Practice Address - State:MI
Practice Address - Zip Code:49663-9124
Practice Address - Country:US
Practice Address - Phone:231-824-6383
Practice Address - Fax:231-824-6939
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF830279137171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor