Provider Demographics
NPI:1669414801
Name:SHIVERS, JULIETTE (NUTRION PROFESSIONAL)
Entity type:Individual
Prefix:MISS
First Name:JULIETTE
Middle Name:
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:NUTRION PROFESSIONAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 E GREGG ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-5158
Mailing Address - Country:US
Mailing Address - Phone:318-572-6157
Mailing Address - Fax:800-708-7349
Practice Address - Street 1:219 E GREGG ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-5158
Practice Address - Country:US
Practice Address - Phone:318-572-6157
Practice Address - Fax:800-708-7349
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21130OtherMEDICARE PART B PROVIDER
TX00696FOtherMEDICARE PART B PROVIDER