Healthcare Provider Details

I. General information

NPI: 1962858480
Provider Name (Legal Business Name): BONNIE C WILSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 MARTIN LUTHER KING PKWY
DURHAM NC
27707-6336
US

IV. Provider business mailing address

2000 PERIMETER PARK DR
MORRISVILLE NC
27560-0198
US

V. Phone/Fax

Practice location:
  • Phone: 919-748-4990
  • Fax:
Mailing address:
  • Phone: 984-215-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL005078
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: