Provider Demographics
NPI:1770116402
Name:VINOKUROVA- SHANNON, ELENA (RD LDN)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:VINOKUROVA- SHANNON
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 1:71B CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-3060
Mailing Address - Country:US
Mailing Address - Phone:781-270-5134
Mailing Address - Fax:
Practice Address - Street 1:24 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6359
Practice Address - Country:US
Practice Address - Phone:617-223-1941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered