Provider Demographics
NPI:1609971639
Name:SHIMON, JEANICE A (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:JEANICE
Middle Name:A
Last Name:SHIMON
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-2407
Mailing Address - Country:US
Mailing Address - Phone:620-221-2300
Mailing Address - Fax:620-221-3594
Practice Address - Street 1:1300 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-2407
Practice Address - Country:US
Practice Address - Phone:620-221-2300
Practice Address - Fax:620-221-3594
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS230133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS486005089OtherCOMMERCIAL
KS000030OtherBLUE CROSS
KS014013OtherBLUE SHIELD
KS100005090AMedicaid
KS486005089OtherCOMMERCIAL
KS014013Medicare ID - Type Unspecified