Provider Demographics
NPI:1417165176
Name:WEGMAN, SHELLY HOWARD (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:HOWARD
Last Name:WEGMAN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FRIDAY CENTER DRIVE,
Mailing Address - Street 2:SUITE 2091, ROOM 2094 HEDRICK BUILDING
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-9499
Mailing Address - Country:US
Mailing Address - Phone:984-974-1191
Mailing Address - Fax:984-974-1311
Practice Address - Street 1:1400 TIMBER DRIVE EAST
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-6925
Practice Address - Country:US
Practice Address - Phone:919-661-6100
Practice Address - Fax:919-661-6101
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002059133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ50643E853OtherMEDICARE PTAN
NCQ50643AOtherMEDICARE PTAN