Provider Demographics
NPI:1861072712
Name:BROWN, BONNIE J
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:BROWN
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 1:9300 GRANT AVE.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-382-6871
Mailing Address - Fax:703-682-6872
Practice Address - Street 1:9300 GRANT AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-382-6871
Practice Address - Fax:703-682-6872
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
171400000XOtherNATIONAL MEDICAL BOARD