Provider Demographics
NPI:1639755721
Name:WILSON, SHAWNA JO (RDN, LD)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 HILLDALE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISPORT
Mailing Address - State:KY
Mailing Address - Zip Code:42351-7036
Mailing Address - Country:US
Mailing Address - Phone:270-922-0890
Mailing Address - Fax:
Practice Address - Street 1:1498 HILLDALE RD
Practice Address - Street 2:
Practice Address - City:LEWISPORT
Practice Address - State:KY
Practice Address - Zip Code:42351-7036
Practice Address - Country:US
Practice Address - Phone:270-922-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty