Provider Demographics
NPI:1942598917
Name:SCOTT, SHANNON MARIE (RD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 SCOTT CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4664
Mailing Address - Country:US
Mailing Address - Phone:601-201-3926
Mailing Address - Fax:
Practice Address - Street 1:1192 SCOTT CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4664
Practice Address - Country:US
Practice Address - Phone:601-201-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1440133V00000X, 133N00000X
TN2326133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist