Provider Demographics
NPI:1881998128
Name:SHELLY, GWENDOLYN (RD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:SHELLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:NISSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3374
Mailing Address - Country:US
Mailing Address - Phone:717-299-6372
Mailing Address - Fax:717-325-8057
Practice Address - Street 1:625 S DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4509
Practice Address - Country:US
Practice Address - Phone:717-299-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000747-1133V00000X
PADN007411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered