Provider Demographics
NPI:1356423024
Name:WICKMAN, SHANNON MOONEY (RD, LDN, CSOWM)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MOONEY
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:RD, LDN, CSOWM
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:MARGARET
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:72 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7021
Mailing Address - Country:US
Mailing Address - Phone:207-467-8825
Mailing Address - Fax:207-467-8811
Practice Address - Street 1:72 MAIN ST
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7021
Practice Address - Country:US
Practice Address - Phone:207-467-8825
Practice Address - Fax:207-467-8811
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2439133V00000X
MEDI1082133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered