Provider Demographics
NPI:1083253090
Name:GRANT-HAILEY, SHANNON (RD, CDN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GRANT-HAILEY
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 KOSSUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2410
Mailing Address - Country:US
Mailing Address - Phone:718-920-8468
Mailing Address - Fax:718-654-7648
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-8468
Practice Address - Fax:718-654-7648
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered