Provider Demographics
NPI:1386657906
Name:BONGE, EDITH (RD/LD)
Entity type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:
Last Name:BONGE
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 LIMOGES CT
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6765
Mailing Address - Country:US
Mailing Address - Phone:501-851-0238
Mailing Address - Fax:
Practice Address - Street 1:4300 WEST 7TH ST
Practice Address - Street 2:11HC/LR
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-257-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered