Provider Demographics
NPI:1518154251
Name:SHEDORICK, MILDRED (RD)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:SHEDORICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MILLIE
Other - Middle Name:
Other - Last Name:SHEDORICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:2412 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-5205
Mailing Address - Country:US
Mailing Address - Phone:516-797-1366
Mailing Address - Fax:
Practice Address - Street 1:2412 HUDSON ST
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-5205
Practice Address - Country:US
Practice Address - Phone:516-797-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001141-1133N00000X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP93860Medicare UPIN
NY9144EEK061Medicare PIN