Provider Demographics
NPI:1942823976
Name:PRESTON, SHELBY NICHOLE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:NICHOLE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MS
Other - First Name:SHELBY
Other - Middle Name:NICHOLE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8111 TOWNSHIP LINE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-338-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86065894133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered