Provider Demographics
NPI:1841613759
Name:RANDALL, SHANNON (RD, LDN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CABANA VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5224
Mailing Address - Country:US
Mailing Address - Phone:321-696-5777
Mailing Address - Fax:
Practice Address - Street 1:355 CABANA VIEW WAY
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5224
Practice Address - Country:US
Practice Address - Phone:321-696-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 6401133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered