Basic Information
| Provider Information | |||||||||
| NPI: | 1588248082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONISESE | ||||||||
| FirstName: | ANGELICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 MACK BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181035622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3080 HAMILTON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181033692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846614641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2021 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN007175 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.