Provider Demographics
NPI:1891136651
Name:IRVIN, BONITA CHRISTIANSEN (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:CHRISTIANSEN
Last Name:IRVIN
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 1:420 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-5033
Mailing Address - Country:US
Mailing Address - Phone:828-315-5000
Mailing Address - Fax:828-304-1234
Practice Address - Street 1:415 N CENTER ST
Practice Address - Street 2:SUITE 002
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-5057
Practice Address - Country:US
Practice Address - Phone:828-322-6699
Practice Address - Fax:828-304-1234
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000632133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2992129Medicare PIN