Provider Demographics
NPI:1679848485
Name:GREGG, SHANNON NICOLE (RD, LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:GREGG
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 RIO RANCHO DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1052
Mailing Address - Country:US
Mailing Address - Phone:505-896-8600
Mailing Address - Fax:505-895-8687
Practice Address - Street 1:1721 RIO RANCHO DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1052
Practice Address - Country:US
Practice Address - Phone:505-896-8600
Practice Address - Fax:505-895-8687
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0852133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered