Provider Demographics
NPI:1689225880
Name:SHIELDS, NICHOLAS A
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4335 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1212
Mailing Address - Country:US
Mailing Address - Phone:831-726-6612
Mailing Address - Fax:
Practice Address - Street 1:4335 UTAH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1212
Practice Address - Country:US
Practice Address - Phone:831-726-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86091088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered