Provider Demographics
NPI:1134754427
Name:ANDERSON, BONNIE (DC)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 NE WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4468
Mailing Address - Country:US
Mailing Address - Phone:503-901-4748
Mailing Address - Fax:
Practice Address - Street 1:3539 N WILLIAMS AVE STE 202A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1437
Practice Address - Country:US
Practice Address - Phone:503-901-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor