Provider Demographics
NPI:1437577210
Name:MUCKENFUSS, SHANNON (RD, LDN, CDE)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:MUCKENFUSS
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8339
Mailing Address - Country:US
Mailing Address - Phone:803-448-6147
Mailing Address - Fax:
Practice Address - Street 1:165 S TRADE ST STE 2C
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5771
Practice Address - Country:US
Practice Address - Phone:704-846-7105
Practice Address - Fax:704-246-6808
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002479133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered