Healthcare Provider Details

I. General information

NPI: 1912767591
Provider Name (Legal Business Name): BONNIE KNOWS BREAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 GLENRIDGE PARK PL STE 8
LOUISVILLE KY
40222-3450
US

IV. Provider business mailing address

1341 S 2ND ST
LOUISVILLE KY
40208-2303
US

V. Phone/Fax

Practice location:
  • Phone: 270-202-9545
  • Fax:
Mailing address:
  • Phone: 270-202-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: BONNIE HOLT LOGSDON
Title or Position: LACTATION CONSULTANT, OWNER
Credential: RD, IBCLC
Phone: 270-202-9545