Provider Demographics
NPI:1073903837
Name:CLEVEN, BONNIE MARIE (RD, CD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:MARIE
Last Name:CLEVEN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 GRIGNON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3020
Mailing Address - Country:US
Mailing Address - Phone:920-857-9093
Mailing Address - Fax:
Practice Address - Street 1:1207 GRIGNON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3020
Practice Address - Country:US
Practice Address - Phone:920-857-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2836-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered