Provider Demographics
NPI:1841618261
Name:BEARDSLEY, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:BEARDSLEY
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 1:1616 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4012
Mailing Address - Country:US
Mailing Address - Phone:209-404-7856
Mailing Address - Fax:
Practice Address - Street 1:1616 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4012
Practice Address - Country:US
Practice Address - Phone:209-404-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA716890133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered