Provider Demographics
NPI:1841798964
Name:DUFRESNE, SHANTEL R (RD)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:R
Last Name:DUFRESNE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SHANTEL
Other - Middle Name:R
Other - Last Name:SECHRIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:5140 LIBERTY AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2215
Mailing Address - Country:US
Mailing Address - Phone:724-941-7490
Mailing Address - Fax:412-315-3530
Practice Address - Street 1:5140 LIBERTY AVE FL 2
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2215
Practice Address - Country:US
Practice Address - Phone:724-941-7490
Practice Address - Fax:412-315-3530
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005448133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103444792Medicaid