Provider Demographics
NPI:1720531825
Name:RODMAN-COSTLOW, SHANNON (RD LD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RODMAN-COSTLOW
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-4475
Mailing Address - Country:US
Mailing Address - Phone:774-405-4016
Mailing Address - Fax:
Practice Address - Street 1:175 CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-4475
Practice Address - Country:US
Practice Address - Phone:774-405-4016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003923133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered