Basic Information
| Provider Information | |||||||||
| NPI: | 1962858480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275600198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842154000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1821 MARTIN LUTHER KING PKWY | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197484990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2016 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L005078 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.