Healthcare Provider Details

I. General information

NPI: 1053427211
Provider Name (Legal Business Name): MARIA RITA BALLESTEROS BONO RN, RD, CDCES, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/28/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 WELLNESS WAY
BOZEMAN MT
59718-1999
US

IV. Provider business mailing address

3905 WELLNESS WAY
BOZEMAN MT
59718-1999
US

V. Phone/Fax

Practice location:
  • Phone: 406-898-1957
  • Fax: 406-898-1959
Mailing address:
  • Phone: 406-898-1957
  • Fax: 406-898-1959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number358712-4901
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number358712-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: