Provider Demographics
NPI:1427415348
Name:SHANNON, CHELSEA (MS RD/LD)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MS RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14025 N EASTERN AVE
Mailing Address - Street 2:APT 1302
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5588
Mailing Address - Country:US
Mailing Address - Phone:316-680-0081
Mailing Address - Fax:
Practice Address - Street 1:14025 N EASTERN AVE
Practice Address - Street 2:APT 1302
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5588
Practice Address - Country:US
Practice Address - Phone:316-680-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2096133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered