Healthcare Provider Details

I. General information

NPI: 1174553325
Provider Name (Legal Business Name): SHIRLEY DAKIN RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/16/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 DAVID L GOLDFEIN ST BLDG 23
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

11 ROSE WOOD DR
MC HENRY MS
39561-6186
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-5785
  • Fax:
Mailing address:
  • Phone: 228-523-5154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number851068
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number851068
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: