Provider Demographics
NPI:1033250733
Name:SMITH, SHANNON ELAINE (RD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ELAINE
Last Name:SMITH
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 1:2150 PACIFIC BEACH DR APT 323
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5624
Mailing Address - Country:US
Mailing Address - Phone:760-272-7097
Mailing Address - Fax:
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:858-939-3478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R814381133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered