Provider Demographics
NPI:1003388315
Name:WOLFSON, SHIRA (RD)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:WOLFSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1487 E TERRACE CIR APT 6
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-5220
Mailing Address - Country:US
Mailing Address - Phone:347-346-1449
Mailing Address - Fax:
Practice Address - Street 1:522 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5221
Practice Address - Country:US
Practice Address - Phone:718-435-5009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NY009838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty