Provider Demographics
NPI:1023194834
Name:MOSER, SHANNON LYNN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:MOSER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 W HIGGINS RD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60195-3200
Mailing Address - Country:US
Mailing Address - Phone:847-285-4200
Mailing Address - Fax:847-885-0130
Practice Address - Street 1:1030 W HIGGINS RD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60195-3200
Practice Address - Country:US
Practice Address - Phone:847-285-4200
Practice Address - Fax:847-885-0130
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK34165Medicare ID - Type UnspecifiedGROUP # 207851
ILK34164Medicare ID - Type UnspecifiedGROUP # 207937