Provider Demographics
NPI:1316213036
Name:BURT, BONNIE ANN (RD)
Entity Type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:ANN
Last Name:BURT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:BONNIE
Other - Middle Name:ANN
Other - Last Name:BURT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:1000 S COAST DR APT E104
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7717
Mailing Address - Country:US
Mailing Address - Phone:562-745-7920
Mailing Address - Fax:
Practice Address - Street 1:1000 S COAST DR APT E104
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7717
Practice Address - Country:US
Practice Address - Phone:562-745-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA932458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered