Provider Demographics
NPI:1548384647
Name:WALSH, BONNIE LEANNE (MSE, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LEANNE
Last Name:WALSH
Suffix:
Gender:F
Credentials:MSE, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 VINEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2439
Mailing Address - Country:US
Mailing Address - Phone:704-786-9181
Mailing Address - Fax:704-792-9198
Practice Address - Street 1:1065 VINEHAVEN DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2439
Practice Address - Country:US
Practice Address - Phone:704-786-9181
Practice Address - Fax:704-792-9198
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001205133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL001205OtherLICENSED DIETITIAN
713894OtherREGISTERRED DITITIAN RD