Provider Demographics
NPI:1619644960
Name:SHELTON, ANOUK DANIELLE (MBA, RD, LD, CNSC)
Entity Type:Individual
Prefix:MRS
First Name:ANOUK
Middle Name:DANIELLE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MBA, RD, LD, CNSC
Other - Prefix:MISS
Other - First Name:ANOUK
Other - Middle Name:DANIELLE
Other - Last Name:BREUKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16151 PETRO DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6422
Mailing Address - Country:US
Mailing Address - Phone:815-342-6205
Mailing Address - Fax:
Practice Address - Street 1:300 S SAINT LOUIS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3043
Practice Address - Country:US
Practice Address - Phone:574-301-5205
Practice Address - Fax:574-301-5205
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003364A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered