Healthcare Provider Details

I. General information

NPI: 1548384647
Provider Name (Legal Business Name): BONNIE LEANNE WALSH MSE, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 VINEHAVEN DR
CONCORD NC
28025-2439
US

IV. Provider business mailing address

1065 VINEHAVEN DR
CONCORD NC
28025-2439
US

V. Phone/Fax

Practice location:
  • Phone: 704-786-9181
  • Fax: 704-792-9198
Mailing address:
  • Phone: 704-786-9181
  • Fax: 704-792-9198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberL001205
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: