Healthcare Provider Details

I. General information

NPI: 1760744130
Provider Name (Legal Business Name): SHANNON RAE HEFFERN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N. BEAVER
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

1200 N. BEAVER PAYER CREDENTIALING
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-2800
  • Fax: 928-773-2421
Mailing address:
  • Phone: 928-213-6235
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number706932
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: