Provider Demographics
NPI:1043699127
Name:ROORDA, BONNIE (PHD, ATC)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:ROORDA
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:VAN LUNEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, ATC
Mailing Address - Street 1:26 SPINDRIFT TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN SHORES
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3721
Mailing Address - Country:US
Mailing Address - Phone:252-305-0121
Mailing Address - Fax:
Practice Address - Street 1:26 SPINDRIFT TRL
Practice Address - Street 2:
Practice Address - City:SOUTHERN SHORES
Practice Address - State:NC
Practice Address - Zip Code:27949-3721
Practice Address - Country:US
Practice Address - Phone:252-305-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0126002802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer