Provider Demographics
NPI:1518749514
Name:BALLS, SHELLEY (MDA, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BALLS
Suffix:
Gender:F
Credentials:MDA, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:SMOOT
Mailing Address - State:WY
Mailing Address - Zip Code:83126-0141
Mailing Address - Country:US
Mailing Address - Phone:307-799-4048
Mailing Address - Fax:
Practice Address - Street 1:206 COTTONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:SMOOT
Practice Address - State:WY
Practice Address - Zip Code:83126
Practice Address - Country:US
Practice Address - Phone:307-799-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty