Provider Demographics
NPI:1508604513
Name:RODRIGUEZ, SHANICE (RD)
Entity type:Individual
Prefix:MRS
First Name:SHANICE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6789 CLEARY LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-7074
Mailing Address - Country:US
Mailing Address - Phone:505-366-8034
Mailing Address - Fax:
Practice Address - Street 1:6789 CLEARY LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7074
Practice Address - Country:US
Practice Address - Phone:505-366-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered