Provider Demographics
NPI:1336504141
Name:WILSON, SHANNON L (MS,RD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WEHRLE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7381
Mailing Address - Country:US
Mailing Address - Phone:716-626-7415
Mailing Address - Fax:
Practice Address - Street 1:2801 WEHRLE DR STE 4
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-626-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered