Healthcare Provider Details

I. General information

NPI: 1912284977
Provider Name (Legal Business Name): MOLLY SHATTUCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 JOHN DEERE RD
MOLINE IL
61265-6898
US

IV. Provider business mailing address

2514 3RD ST
MOLINE IL
61265-5105
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-0200
  • Fax:
Mailing address:
  • Phone: 309-781-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number001928
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number164005153
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: