Provider Demographics
NPI:1801488150
Name:CROWTHER, SHANNON (RDN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CROWTHER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:ID
Mailing Address - Zip Code:83237-0009
Mailing Address - Country:US
Mailing Address - Phone:435-770-0894
Mailing Address - Fax:
Practice Address - Street 1:223 S 2600 E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-5423
Practice Address - Country:US
Practice Address - Phone:435-770-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-671133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered