Healthcare Provider Details

I. General information

NPI: 1639647928
Provider Name (Legal Business Name): SHANNON LEIGH BURKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

2791 GREENWICH ST APT 3
SAN FRANCISCO CA
94123-3299
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: