Healthcare Provider Details

I. General information

NPI: 1336039155
Provider Name (Legal Business Name): SHANA PETIT MS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

5 FAVORITE LN
EAST LONGMEADOW MA
01028-3199
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-8847
  • Fax:
Mailing address:
  • Phone: 860-305-8913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number002074
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: