Provider Demographics
NPI:1982112470
Name:SHEA TAN, DANIELLE NICOLE (MS NUTRITION, LDN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:SHEA TAN
Suffix:
Gender:F
Credentials:MS NUTRITION, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2314
Mailing Address - Country:US
Mailing Address - Phone:617-921-7977
Mailing Address - Fax:
Practice Address - Street 1:8 MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2314
Practice Address - Country:US
Practice Address - Phone:617-921-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education