Provider Demographics
NPI:1740750835
Name:SHETTLE, LISA (RDN CDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SHETTLE
Suffix:
Gender:F
Credentials:RDN CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 KELSEY LN
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5040
Mailing Address - Country:US
Mailing Address - Phone:860-916-2486
Mailing Address - Fax:
Practice Address - Street 1:65 KELSEY LN
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5040
Practice Address - Country:US
Practice Address - Phone:860-916-2486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered