Provider Demographics
NPI:1598838609
Name:GRUBE, SHANNON (MS, RDN, CD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:GRUBE
Suffix:
Gender:F
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 SW JUDSON DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5802
Mailing Address - Country:US
Mailing Address - Phone:360-544-2466
Mailing Address - Fax:360-873-0017
Practice Address - Street 1:658 SE BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5700
Practice Address - Country:US
Practice Address - Phone:360-544-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001748133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
93-2187230OtherDEPARTMENT OF TREASURY