Provider Demographics
NPI:1831231059
Name:RENTZ, SHANNON MARIE (RD, LD)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:RENTZ
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 1:2333 SE CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-6380
Mailing Address - Country:US
Mailing Address - Phone:503-494-8636
Mailing Address - Fax:503-494-3769
Practice Address - Street 1:OREGON HEALTH & SCIENCES UNIVERSITY, MAIL CODE UHS 18
Practice Address - Street 2:3181 SW SAM JACKSON PARK RD
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-8636
Practice Address - Fax:503-494-3769
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP73534Medicare UPIN
OR114309Medicare ID - Type Unspecified