Provider Demographics
NPI:1780226795
Name:SHAW, CALLIE ALTHEA (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:ALTHEA
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N ROADRUNNER PKWY APT 801
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9054
Mailing Address - Country:US
Mailing Address - Phone:724-464-7721
Mailing Address - Fax:
Practice Address - Street 1:2669 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8700
Practice Address - Country:US
Practice Address - Phone:575-443-7451
Practice Address - Fax:575-443-7458
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1327133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered