Healthcare Provider Details

I. General information

NPI: 1376024281
Provider Name (Legal Business Name): HEATHAR SHEPARD NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MISTY VALLEY DR
CANTON GA
30114-7732
US

IV. Provider business mailing address

PO BOX 464
QUESTA NM
87556-0464
US

V. Phone/Fax

Practice location:
  • Phone: 770-516-2303
  • Fax:
Mailing address:
  • Phone: 505-204-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: