Provider Demographics
NPI:1164565305
Name:SHELTON, TARA SHAWN (RD,LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SHAWN
Last Name:SHELTON
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 STILES RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-9440
Mailing Address - Country:US
Mailing Address - Phone:270-898-1257
Mailing Address - Fax:
Practice Address - Street 1:716 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2546
Practice Address - Country:US
Practice Address - Phone:270-762-1806
Practice Address - Fax:270-762-1805
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1292133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3322842Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY