Provider Demographics
NPI:1407159361
Name:BERGTHOLDT, SHANNAN E (MS ED, RD)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:E
Last Name:BERGTHOLDT
Suffix:
Gender:F
Credentials:MS ED, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8116 ASHTONBIRCH DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-3021
Mailing Address - Country:US
Mailing Address - Phone:757-288-5727
Mailing Address - Fax:757-210-5386
Practice Address - Street 1:8116 ASHTONBIRCH DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-3021
Practice Address - Country:US
Practice Address - Phone:757-288-5727
Practice Address - Fax:757-210-5386
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered