Healthcare Provider Details

I. General information

NPI: 1093139677
Provider Name (Legal Business Name): SHELLY EDENS R.D., C.S.O., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MEMORIAL MEDICAL PKWY FOOD AND NUTRITION DEPARTMENT
PALM COAST FL
32164-5980
US

IV. Provider business mailing address

8539 GATE PKWY W UNIT 1435
JACKSONVILLE FL
32216-1019
US

V. Phone/Fax

Practice location:
  • Phone: 386-586-4320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: