Individual
MARY T. BONACCORSI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN, DNP, FNP
Contact information
Practice address
903 MINERAL POINT AVE, JANESVILLE, WI 53548-2970
(608) 756-5555
(608) 756-0174
Mailing address
903 MINERAL POINT AVE, JANESVILLE, WI 53548-2970
(608) 756-5555
(608) 756-0174
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
209004213
IL
363LF0000X
Family Nurse Practitioner
2628-033
WI
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
2628-33
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000054176-K400333954
WI MEDICARE
WI
01
—
000084908-K400332994
WI MEDICARE
WI
05
—
041305302
—
IL
01
—
1811927205
BCBSWI
WI
05
—
1811927205
—
WI
01
—
406120105
PTAN
—
01
—
BONACMAR
MERCYCARE INSURANCE
WI
Enumeration date
07/03/2006
Last updated
07/21/2022
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