Provider Demographics
NPI:1164573275
Name:GREEN, SHANNON (RD CDE CSR LDN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD CDE CSR LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 HORSEMAN CT
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4065
Mailing Address - Country:US
Mailing Address - Phone:410-877-6077
Mailing Address - Fax:410-877-6087
Practice Address - Street 1:1011 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1318
Practice Address - Country:US
Practice Address - Phone:410-877-6077
Practice Address - Fax:410-877-6087
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01526133V00000X, 133VN1006X, 133VN1005X, 133N00000X, 133NN1002X, 133VN1004X
DCDI100000367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61553701OtherCAREFIRST BLUE CROSS BLUE SHIEDL
MDG3980001OtherGROUP HOSPITALIZATION AND MEDICAL SERVICES, INC
MD3072804OtherAETNA, HMO
MD400754900Medicaid
MD7455454OtherAETNA,NON HMO
2122754OtherUNITEDHEALTHCARE
2122754OtherUNITEDHEALTHCARE
DC150409ZDGZMedicare PIN
P52275Medicare UPIN