Provider Demographics
NPI:1083265730
Name:WINTERBOTTOM, SARA BONCZEWSKI (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:BONCZEWSKI
Last Name:WINTERBOTTOM
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:BONCZEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:7125 BEAVER TRL
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-9549
Mailing Address - Country:US
Mailing Address - Phone:714-380-8006
Mailing Address - Fax:
Practice Address - Street 1:1617 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-9021
Practice Address - Country:US
Practice Address - Phone:919-577-9952
Practice Address - Fax:919-577-9946
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005537133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered