Provider Demographics
NPI:1053620849
Name:MALMBERG, BONNIE BRYDE (MSN, CNNP)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:BRYDE
Last Name:MALMBERG
Suffix:
Gender:F
Credentials:MSN, CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4255
Mailing Address - Country:US
Mailing Address - Phone:612-600-6665
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-520-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN192891-6363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care