Provider Demographics
NPI:1669002226
Name:WILLY, SHARI ROSE (RD, LDE)
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:ROSE
Last Name:WILLY
Suffix:
Gender:F
Credentials:RD, LDE
Other - Prefix:
Other - First Name:SHARI
Other - Middle Name:ROSE
Other - Last Name:NAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # 5A6B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-4940
Practice Address - Fax:502-588-7712
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY124742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered