Provider Demographics
NPI:1073585493
Name:CLYDE, SHELLY LYNN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:LYNN
Last Name:CLYDE
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:HHC 121 GENERAL HOSPITAL
Mailing Address - Street 2:BOX 663
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205
Mailing Address - Country:US
Mailing Address - Phone:0118227-917-5302
Mailing Address - Fax:0118227-917-3251
Practice Address - Street 1:HHC 121 GENERAL HOSPITAL
Practice Address - Street 2:BOX 663
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205
Practice Address - Country:US
Practice Address - Phone:0118227-917-5302
Practice Address - Fax:0118227-917-3251
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06316133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered