Healthcare Provider Details

I. General information

NPI: 1164573275
Provider Name (Legal Business Name): SHANNON GREEN RD CDE CSR LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 INGLESIDE AVE
CATONSVILLE MD
21228-1318
US

IV. Provider business mailing address

51 HORSEMAN CT
RANDALLSTOWN MD
21133-4065
US

V. Phone/Fax

Practice location:
  • Phone: 410-877-6077
  • Fax: 410-877-6087
Mailing address:
  • Phone: 410-877-6077
  • Fax: 410-877-6087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD01526
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI100000367
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD01526
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberD01526
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberD01526
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberD01526
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD01526
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: