Provider Demographics
NPI:1811318728
Name:CAVANAGH, BONNIE (RD, LD)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:LYNN
Other - Last Name:BUCKINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3517 NW SAMARITAN DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3768
Practice Address - Country:US
Practice Address - Phone:541-768-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10160158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLD-D-10160158OtherOREGON HEALTH LICENSING
OR1078859OtherCOMMISSION ON DIETETIC REGISTRATION