Provider Demographics
NPI:1275540478
Name:COPPERSMITH, SHAWNEE M (RD LDN/LD)
Entity Type:Individual
Prefix:
First Name:SHAWNEE
Middle Name:M
Last Name:COPPERSMITH
Suffix:
Gender:F
Credentials:RD LDN/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-1530
Mailing Address - Country:US
Mailing Address - Phone:814-931-3363
Mailing Address - Fax:
Practice Address - Street 1:15 SOUTH MONTGOMERY STREET
Practice Address - Street 2:LYTLE BEHAVIORAL HEALTH
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648
Practice Address - Country:US
Practice Address - Phone:814-696-3277
Practice Address - Fax:814-695-5307
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003422133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered