Provider Demographics
NPI:1669207916
Name:SHACKELFORD, BETSY RUTH (RDN)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:RUTH
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 WESLEY CT
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3727
Mailing Address - Country:US
Mailing Address - Phone:630-945-7570
Mailing Address - Fax:
Practice Address - Street 1:1574 WESLEY CT
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3727
Practice Address - Country:US
Practice Address - Phone:630-945-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered