Healthcare Provider Details

I. General information

NPI: 1790972313
Provider Name (Legal Business Name): SHANNON ROQUE RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SOUTH ST
MORRISTOWN NJ
07960-6422
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-7983
US

V. Phone/Fax

Practice location:
  • Phone: 973-971-7166
  • Fax: 973-290-7518
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number960240
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: