Provider Demographics
NPI:1407222920
Name:SHODIMU, ELIZABETH O (LICENSE)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:O
Last Name:SHODIMU
Suffix:
Gender:F
Credentials:LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111-08 WITTHOFF STREET
Mailing Address - Street 2:
Mailing Address - City:QUEEN'S VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429
Mailing Address - Country:US
Mailing Address - Phone:917-658-5068
Mailing Address - Fax:
Practice Address - Street 1:110-16 SUTPHIN BLVD
Practice Address - Street 2:111-08 WITTHOFF STREET
Practice Address - City:QUEEN'S VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429
Practice Address - Country:US
Practice Address - Phone:917-658-5068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004988-1133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered