Provider Demographics
NPI:1093010852
Name:MCGEHEE, DARRELL SHANNON (LD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:SHANNON
Last Name:MCGEHEE
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-0190
Mailing Address - Country:US
Mailing Address - Phone:352-318-2646
Mailing Address - Fax:
Practice Address - Street 1:37 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2681
Practice Address - Country:US
Practice Address - Phone:352-528-0022
Practice Address - Fax:352-528-2878
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 4357133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist