Provider Demographics
NPI:1275795734
Name:BONHAM, KAREN MARIE (RD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:BONHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:550 S JACKSON ST
Practice Address - Street 2:1S FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-562-6503
Practice Address - Fax:502-562-6504
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0541133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0048468Medicare PIN
KY01174004Medicare PIN
KY0631271Medicare PIN
KY0523971Medicare PIN