Provider Demographics
NPI:1235231218
Name:BARE, SHANA VAUGHAN (RD LDN CDE)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:VAUGHAN
Last Name:BARE
Suffix:
Gender:F
Credentials:RD LDN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 GARFFE SHERRON RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-8906
Mailing Address - Country:US
Mailing Address - Phone:919-556-3189
Mailing Address - Fax:
Practice Address - Street 1:12720 GARFFE SHERRON RD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-8906
Practice Address - Country:US
Practice Address - Phone:919-556-3189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001257133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2992183Medicare ID - Type UnspecifiedPROVIDER NUMBER