Provider Demographics
NPI:1073826137
Name:SHEARER, ELYSE ALEXANDRA (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:ELYSE
Middle Name:ALEXANDRA
Last Name:SHEARER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CAPEWOOD RD
Mailing Address - Street 2:APT. 225
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-2701
Mailing Address - Country:US
Mailing Address - Phone:716-523-4326
Mailing Address - Fax:
Practice Address - Street 1:22725 HIGHWAY 76 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7527
Practice Address - Country:US
Practice Address - Phone:864-833-9369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLRD.846 RD133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered