Provider Demographics
NPI:1093258030
Name:WISE, SHANNON (RD, LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 RIO MESA DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732
Mailing Address - Country:US
Mailing Address - Phone:415-260-8995
Mailing Address - Fax:
Practice Address - Street 1:2409 RIO MESA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732-1964
Practice Address - Country:US
Practice Address - Phone:415-260-8995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered