Provider Demographics
NPI:1205960705
Name:POOLE, SHIRLEY JEAN (RD CSP LDN)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:JEAN
Last Name:POOLE
Suffix:
Gender:F
Credentials:RD CSP LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11249 CHANEY DR
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-7438
Mailing Address - Country:US
Mailing Address - Phone:815-489-4667
Mailing Address - Fax:815-967-5404
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-489-4667
Practice Address - Fax:815-964-5404
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric