Provider Demographics
NPI:1982225868
Name:PARKS, SHANNON R (RDN/LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:PARKS
Suffix:
Gender:F
Credentials:RDN/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 PLAZA ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-4446
Mailing Address - Country:US
Mailing Address - Phone:727-488-1288
Mailing Address - Fax:
Practice Address - Street 1:902 PLAZA ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-4446
Practice Address - Country:US
Practice Address - Phone:727-488-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2427133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered