Provider Demographics
NPI:1801491345
Name:DEFIORE, BONNIE (RD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:DEFIORE
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 1:5 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 CHALLENGER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-1041
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT59.001891133V00000X
MEDI1638133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered