Provider Demographics
NPI:1144598889
Name:MEDENWALD, SHANNON (RD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MEDENWALD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 CALICO DR S
Mailing Address - Street 2:APT 303
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8744
Mailing Address - Country:US
Mailing Address - Phone:701-200-7233
Mailing Address - Fax:
Practice Address - Street 1:300 22ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2480
Practice Address - Country:US
Practice Address - Phone:605-696-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered