Provider Demographics
NPI:1902359771
Name:BOONSTRA, FAWN (RD)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 S CORNWALL DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-4812
Mailing Address - Country:US
Mailing Address - Phone:602-206-2017
Mailing Address - Fax:480-962-0202
Practice Address - Street 1:99 S. GOLD DR. SUITE 5
Practice Address - Street 2:GOLDFIELD CARDIOVASCULAR INSTITUTE
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120
Practice Address - Country:US
Practice Address - Phone:480-962-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered