Provider Demographics
NPI:1245619493
Name:SHANNON, MARY ANN (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3516
Mailing Address - Country:US
Mailing Address - Phone:630-347-0526
Mailing Address - Fax:
Practice Address - Street 1:1801 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-3516
Practice Address - Country:US
Practice Address - Phone:630-347-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL443568133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered