Healthcare Provider Details

I. General information

NPI: 1487136578
Provider Name (Legal Business Name): BONITA RUTKOWSKI IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BONNIE GOTTSMAN

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W BETH WALD ST
EL PASO TX
79938-0707
US

IV. Provider business mailing address

212 W BETH WALD ST
EL PASO TX
79938-0707
US

V. Phone/Fax

Practice location:
  • Phone: 915-490-9147
  • Fax:
Mailing address:
  • Phone: 915-490-9147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-108420
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: