Provider Demographics
NPI:1831602994
Name:HAZEL, SHELBY L (RDN, LD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:HAZEL
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:L
Other - Last Name:WILKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11744 SW 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7017
Mailing Address - Country:US
Mailing Address - Phone:503-910-1409
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:360-726-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician