Provider Demographics
NPI:1174003529
Name:SHANNON-ESPINOZA, KATHERINE MARY (MSRD)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:MARY
Last Name:SHANNON-ESPINOZA
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MILLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2834
Mailing Address - Country:US
Mailing Address - Phone:631-897-7713
Mailing Address - Fax:
Practice Address - Street 1:31 BROADWAY
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1320
Practice Address - Country:US
Practice Address - Phone:631-897-7713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY708288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered