Provider Demographics
NPI:1982734828
Name:MICHAELSON, BONITA A
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:A
Last Name:MICHAELSON
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 1:1001 WAITE DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2733
Mailing Address - Country:US
Mailing Address - Phone:612-325-0336
Mailing Address - Fax:
Practice Address - Street 1:280 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-743-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO169907163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
016700OtherKAISER-COMMERCIAL NUMBER