Healthcare Provider Details

I. General information

NPI: 1588059992
Provider Name (Legal Business Name): COURTNEY BONILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

15803 ROLAND VIEW DR
CHESTER VA
23831-7246
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5000
  • Fax:
Mailing address:
  • Phone: 757-710-3083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number949152
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: