Healthcare Provider Details

I. General information

NPI: 1922243831
Provider Name (Legal Business Name): SHANNON KATHLENE DUFFY R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE 32-263 CHS
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

10833 LE CONTE AVE 32-263 CHS
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-3952
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number913739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: