Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC-002773L | PA |
NPI | 1285665083 |
---|---|
Provider Name | Dr. Bonnie Lee Becker |
First Address | Green Lane, PA 18054-2541 |
Second Address | Telford, PA 18969-1327 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0048435000 | 10-DIGIT HMO ID (01) | PA |