Healthcare Provider Details

I. General information

NPI: 1487624227
Provider Name (Legal Business Name): SHELLY WINGERT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: SHELLY DAVIS

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

IV. Provider business mailing address

PO BOX 1833
SANTA CRUZ CA
95061-1833
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-5597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number958514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: