Healthcare Provider Details

I. General information

NPI: 1588360937
Provider Name (Legal Business Name): SHANNON ELIZABETH BARES RD, CSR, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 STAGECOACH RD
GALLUP NM
87301-6779
US

IV. Provider business mailing address

303 STAGECOACH RD
GALLUP NM
87301-6779
US

V. Phone/Fax

Practice location:
  • Phone: 414-403-0501
  • Fax:
Mailing address:
  • Phone: 414-403-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-1261
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1419
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number461
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number954764
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: