Provider Demographics
NPI:1508443086
Name:WILLIAMS, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 BARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8361
Mailing Address - Country:US
Mailing Address - Phone:801-703-3303
Mailing Address - Fax:
Practice Address - Street 1:3314 BARRINGTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8361
Practice Address - Country:US
Practice Address - Phone:801-703-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1028102OtherCOMMISSION ON DIETETIC REGISTRATION