Provider Demographics
NPI:1972029296
Name:BONHAM, KRISTINE CARLSON (RDN)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:CARLSON
Last Name:BONHAM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 LANFORD HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-9100
Mailing Address - Country:US
Mailing Address - Phone:434-242-2935
Mailing Address - Fax:
Practice Address - Street 1:875 RIO EAST CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8004
Practice Address - Country:US
Practice Address - Phone:434-242-2935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE647296133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty