Provider Demographics
NPI:1457934242
Name:SOUTH, SHANNON (FNTP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:FNTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MANHATTAN AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-4939
Mailing Address - Country:US
Mailing Address - Phone:646-731-9497
Mailing Address - Fax:
Practice Address - Street 1:460 MANHATTAN AVE APT 2A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-4939
Practice Address - Country:US
Practice Address - Phone:646-731-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education