MEDICARE: ROSSIE E BONEFONT MPH, RD,LND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	5178	FL
2	133N00000X	Nutritionist	818	PR
3	133V00000X	Registered Dietitian	706357	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ND5178	OTHER	FL	NUTRICIONIST LICENSE
2	706357	OTHER	FL	DIETICIAN CERTIFICATE

General Provider Information

NPI Number	:	1609014109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSSIE E BONEFONT MPH, RD,LND

Provider Business Mailing Address
First Line	:	PO BOX 616788
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32861-6788
Country	:	US
Telephone Number	:	407-447-7105
Fax Number	:	407-770-0594

Provider Business Practice Location Address
First Line	:	2285 S SEMORAN BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-2703
Country	:	US
Telephone Number	:	407-282-8200
Fax Number	:	407-728-2801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	02/13/2013

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