Provider Demographics
NPI:1073686796
Name:CARROLL, SHANNON LYN (RD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LYN
Last Name:CARROLL
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 1:7392 W DIVISION LINE RD
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-8909
Mailing Address - Country:US
Mailing Address - Phone:765-564-3650
Mailing Address - Fax:
Practice Address - Street 1:2400 SOUTH ST
Practice Address - Street 2:GREATER LAFAYETTE HEALTH SERVICES FOOD AND NUTRITION
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3027
Practice Address - Country:US
Practice Address - Phone:765-449-5139
Practice Address - Fax:765-449-3061
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN848411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered