Provider Demographics
NPI:1093139677
Name:EDENS, SHELLY (RD, CSO, LDN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:EDENS
Suffix:
Gender:F
Credentials:RD, CSO, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8539 GATE PKWY W
Mailing Address - Street 2:UNIT 1435
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:FOOD AND NUTRITION DEPARTMENT
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-586-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5449133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered