Healthcare Provider Details

I. General information

NPI: 1740517028
Provider Name (Legal Business Name): DR. BONNIE M CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2009
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14635 SE 180TH ST
WEIRSDALE FL
32195-3011
US

IV. Provider business mailing address

PO BOX 1102
LADY LAKE FL
32158-1102
US

V. Phone/Fax

Practice location:
  • Phone: 352-821-3312
  • Fax: 352-821-3312
Mailing address:
  • Phone: 352-821-3312
  • Fax: 352-821-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number2923752
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: