Healthcare Provider Details

I. General information

NPI: 1750291951
Provider Name (Legal Business Name): KELLEY TRACEY SHANAHAN RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CLEMENT ST APT 3
WORCESTER MA
01603-2403
US

IV. Provider business mailing address

3724 JEFFERSON ST STE 104
AUSTIN TX
78731-6204
US

V. Phone/Fax

Practice location:
  • Phone: 508-838-7386
  • Fax:
Mailing address:
  • Phone: 512-693-7045
  • Fax: 512-399-9039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86404460
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: