Provider Demographics
NPI:1518187749
Name:BOHANNON, MARY H (RD LDN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:H
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12208 SW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MICANOPY
Mailing Address - State:FL
Mailing Address - Zip Code:32667
Mailing Address - Country:US
Mailing Address - Phone:352-466-3864
Mailing Address - Fax:
Practice Address - Street 1:4001 NEWBERRY RD
Practice Address - Street 2:SUITE C IV
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607
Practice Address - Country:US
Practice Address - Phone:352-374-4449
Practice Address - Fax:352-374-4464
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND00000297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered