Basic Information
| Provider Information | |||||||||
| NPI: | 1609014109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONEFONT | ||||||||
| FirstName: | ROSSIE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPH, RD,LND | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERA | ||||||||
| OtherFirstName: | ROSSIE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPH, RD,LND | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477105 | ||||||||
| FaxNumber: | 4077700594 | ||||||||
| Practice Location | |||||||||
| Address1: | 2285 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328222703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072828200 | ||||||||
| FaxNumber: | 4077282801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 5178 | FL | N | Dietary & Nutritional Service Providers | Nutritionist | 133N00000X | 818 | PR | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 706357 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | ND5178 | 01 | FL | NUTRICIONIST LICENSE | OTHER | 706357 | 01 | FL | DIETICIAN CERTIFICATE | OTHER |