Provider Demographics
NPI:1548805005
Name:ROTH, SHANA LOUISE (RD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LOUISE
Last Name:ROTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1452
Mailing Address - Country:US
Mailing Address - Phone:906-483-1253
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1452
Practice Address - Country:US
Practice Address - Phone:906-483-1148
Practice Address - Fax:906-483-1670
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI930350133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered