Healthcare Provider Details

I. General information

NPI: 1477568913
Provider Name (Legal Business Name): BONNIE JEAN BEYNNON RD CD CNSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE ENGINEERING 328
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE ENGINEERING 328
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3640
  • Fax: 802-847-2790
Mailing address:
  • Phone: 802-847-3640
  • Fax: 802-847-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number074-0000128
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: