Healthcare Provider Details

I. General information

NPI: 1457177925
Provider Name (Legal Business Name): KATIE JUNE SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2024
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PEEWEE HILL RD
NESCOPECK PA
18635-2187
US

IV. Provider business mailing address

1221 PEEWEE HILL RD
NESCOPECK PA
18635-2187
US

V. Phone/Fax

Practice location:
  • Phone: 570-764-8828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN007687
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: