Provider Demographics
NPI:1134305857
Name:LILLIE, BONITA (RD)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:LILLIE
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 1:5412 CASTLE BAR LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5519
Mailing Address - Country:US
Mailing Address - Phone:703-879-5160
Mailing Address - Fax:
Practice Address - Street 1:2121 EISENHOWER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4698
Practice Address - Country:US
Practice Address - Phone:703-519-0901
Practice Address - Fax:703-519-0902
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004009119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02785D01OtherMEDICARE PTAN