Provider Demographics
NPI:1558772319
Name:HAYNES, SHANNON WOODWARD D'AQUILA (RD, CD-N)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:WOODWARD D'AQUILA
Last Name:HAYNES
Suffix:
Gender:F
Credentials:RD, CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 DARLING RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3913
Mailing Address - Country:US
Mailing Address - Phone:860-230-4176
Mailing Address - Fax:
Practice Address - Street 1:354 DARLING RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3913
Practice Address - Country:US
Practice Address - Phone:860-230-4176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000677133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered