Healthcare Provider Details

I. General information

NPI: 1770475204
Provider Name (Legal Business Name): CARLY SHAPIRO RD, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 N 65TH AVE
OMAHA NE
68104-3915
US

IV. Provider business mailing address

2712 N 65TH AVE
OMAHA NE
68104-3915
US

V. Phone/Fax

Practice location:
  • Phone: 608-341-7836
  • Fax:
Mailing address:
  • Phone: 608-341-7836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86046262
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number352680
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: