Healthcare Provider Details

I. General information

NPI: 1073585493
Provider Name (Legal Business Name): SHELLY LYNN CLYDE R.D, L.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HHC 121 GENERAL HOSPITAL BOX 663
APO AP
96205
US

IV. Provider business mailing address

HHC 121 GENERAL HOSPITAL BOX 663
APO AP
96205
US

V. Phone/Fax

Practice location:
  • Phone: 01182279175302
  • Fax: 01182279173251
Mailing address:
  • Phone: 01182279175302
  • Fax: 01182279173251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT06316
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: