Provider Demographics
NPI:1659529378
Name:SHELLEY, LISA RAYNELLE (RD, LD, CDE, BC-ADM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAYNELLE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:RD, LD, CDE, BC-ADM
Other - Prefix:
Other - First Name:RAYNELLE
Other - Middle Name:
Other - Last Name:SHELLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD, CDE, BC-ADM
Mailing Address - Street 1:PO BOX 847556
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7556
Mailing Address - Country:US
Mailing Address - Phone:806-212-0577
Mailing Address - Fax:806-212-0563
Practice Address - Street 1:2460 CURTIS ELLIS DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804
Practice Address - Country:US
Practice Address - Phone:806-212-0577
Practice Address - Fax:806-212-0563
Is Sole Proprietor?:No
Enumeration Date:2008-09-06
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80908133V00000X
NCL005339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
20120483OtherNCBDE
TX942472OtherAMERICAN DIETETIC ASSOCIATION
200913419OtherAMERICAN ASSOCIATION OF DIABETIC EDUCATORS
TXDT80908OtherTEXAS STATE BOARD OF EXAMINERS OF DIETITIANS