Provider Demographics
NPI:1740659226
Name:BOUCHER, SHANNON (MNT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 PONTIAC ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-1831
Mailing Address - Country:US
Mailing Address - Phone:720-382-4574
Mailing Address - Fax:
Practice Address - Street 1:1751 PONTIAC ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-1831
Practice Address - Country:US
Practice Address - Phone:720-382-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist