Provider Demographics
NPI:1851576813
Name:HUSSIN, SHANA M (RD,CD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:M
Last Name:HUSSIN
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8165 BIG LAKE LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9666
Mailing Address - Country:US
Mailing Address - Phone:920-850-3374
Mailing Address - Fax:
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-731-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI894337133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered