Healthcare Provider Details

I. General information

NPI: 1497959845
Provider Name (Legal Business Name): REGINA E. SHELTON LICENSED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 S SAINT LOUIS AVE
CHICAGO IL
60623-2155
US

IV. Provider business mailing address

1531 S SAINT LOUIS AVE
CHICAGO IL
60623-2155
US

V. Phone/Fax

Practice location:
  • Phone: 773-521-4665
  • Fax:
Mailing address:
  • Phone: 773-521-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: