Provider Demographics
NPI:1265857080
Name:SHIELDS, LORETTA B (MS,RD)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:B
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:MS
Other - First Name:LORETTA
Other - Middle Name:B
Other - Last Name:LEESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,RD
Mailing Address - Street 1:130 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2826
Mailing Address - Country:US
Mailing Address - Phone:734-751-6097
Mailing Address - Fax:
Practice Address - Street 1:130 WARREN ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2826
Practice Address - Country:US
Practice Address - Phone:734-751-6097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered