Healthcare Provider Details

I. General information

NPI: 1679988810
Provider Name (Legal Business Name): SHANNON C BRUEGGEMANN MS, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 06/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE SECOND FLOOR
SAINT LOUIS MO
63110-2540
US

IV. Provider business mailing address

3660 VISTA AVE SECOND FLOOR
SAINT LOUIS MO
63110-2540
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6142
  • Fax:
Mailing address:
  • Phone: 314-977-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2004020871
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.003871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: