Healthcare Provider Details

I. General information

NPI: 1477908937
Provider Name (Legal Business Name): BONNIE LYNN HOUSE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 HIGHLAND DR
WASHINGTON NC
27889-3222
US

IV. Provider business mailing address

1436 HIGHLAND DR
WASHINGTON NC
27889-3222
US

V. Phone/Fax

Practice location:
  • Phone: 252-946-1902
  • Fax: 252-946-8430
Mailing address:
  • Phone: 252-946-1902
  • Fax: 252-946-8430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number832818
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: