Provider Demographics
NPI:1225652076
Name:GREEN, BONNIE (RDN, RYT-200)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDN, RYT-200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 532071
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48153-2071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17418 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4802
Practice Address - Country:US
Practice Address - Phone:734-419-3549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2021-03-08
Deactivation Date:2021-02-03
Deactivation Code:
Reactivation Date:2021-03-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education