Provider Demographics
NPI:1770055139
Name:SHEPARDSON, AMY (RD, LDN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHEPARDSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 HAZARD AVE BLDG 4
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4585
Mailing Address - Country:US
Mailing Address - Phone:860-763-0208
Mailing Address - Fax:860-763-0224
Practice Address - Street 1:139 HAZARD AVE BLDG 4
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4585
Practice Address - Country:US
Practice Address - Phone:860-763-0208
Practice Address - Fax:860-763-0224
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001390133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist