Provider Demographics
NPI:1740517028
Name:CARLSON, BONNIE M
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:M
Last Name:CARLSON
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:PO BOX 1102
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1102
Mailing Address - Country:US
Mailing Address - Phone:352-821-3312
Mailing Address - Fax:352-821-3312
Practice Address - Street 1:14635 SE 180TH ST
Practice Address - Street 2:
Practice Address - City:WEIRSDALE
Practice Address - State:FL
Practice Address - Zip Code:32195-3011
Practice Address - Country:US
Practice Address - Phone:352-821-3312
Practice Address - Fax:352-821-3312
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-08
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2923752175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath