Provider Demographics
NPI:1407201080
Name:BONILLA, ROBERT (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MERCER ST
Mailing Address - Street 2:APT 106
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-4792
Mailing Address - Country:US
Mailing Address - Phone:206-909-8022
Mailing Address - Fax:206-909-8022
Practice Address - Street 1:4241 11TH AVE NE
Practice Address - Street 2:SUITE B
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4699
Practice Address - Country:US
Practice Address - Phone:206-909-8022
Practice Address - Fax:206-909-8022
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60646159133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered