Provider Demographics
NPI:1013533678
Name:HOLLISTER, SHANNON JAMES (CERTIFIED NUTRITIONI)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:JAMES
Last Name:HOLLISTER
Suffix:
Gender:M
Credentials:CERTIFIED NUTRITIONI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13936 SR 106
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18826
Mailing Address - Country:US
Mailing Address - Phone:570-468-1528
Mailing Address - Fax:
Practice Address - Street 1:13936 SR 106
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:PA
Practice Address - Zip Code:18826
Practice Address - Country:US
Practice Address - Phone:570-468-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty