Provider Demographics
NPI:1891756730
Name:SHOUP, MELISSA DAWN (RD, MS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
Last Name:SHOUP
Suffix:
Gender:F
Credentials:RD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15664 SMOKEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35469-1025
Mailing Address - Country:US
Mailing Address - Phone:205-344-5743
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5015
Practice Address - Country:US
Practice Address - Phone:205-554-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL930657133V00000X
AL1476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered