Healthcare Provider Details

I. General information

NPI: 1427911296
Provider Name (Legal Business Name): SHIMI VELASQUEZ INCIONG RD, LD, CDM, CFPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 11/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 GOV. CARLOS CAMACHO RD., TAMUNING, GU 96913
TAMUNING GU
96931
US

IV. Provider business mailing address

160 N MARIPOSA CT
DEDEDO GU
96929-5809
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-2330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-048
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: