Provider Demographics
NPI:1659754810
Name:STAMPER, SHANNON LEIAMBRE (RD, CSP, LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIAMBRE
Last Name:STAMPER
Suffix:
Gender:F
Credentials:RD, CSP, LD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEIAMBRE
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CSP, LD
Mailing Address - Street 1:610 W HAYS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-381-7092
Mailing Address - Fax:208-381-7071
Practice Address - Street 1:610 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-381-7092
Practice Address - Fax:208-381-7071
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-874133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric