Provider Demographics
NPI:1326012246
Name:FITZGERALD, SHANNON (RD LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:ODONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:6935 TREELINE DR
Mailing Address - Street 2:STE J
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141
Mailing Address - Country:US
Mailing Address - Phone:440-746-2220
Mailing Address - Fax:440-746-3496
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:SJWS DIETARY SERVICES
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145
Practice Address - Country:US
Practice Address - Phone:440-827-5588
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD3367133V00000X
OHRD800228133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered