Healthcare Provider Details

I. General information

NPI: 1710588686
Provider Name (Legal Business Name): JONATHAN S SHANE FNTP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3038 VILLAGE CREEK DR
KATY TX
77494-6950
US

IV. Provider business mailing address

3038 VILLAGE CREEK DR
KATY TX
77494-6950
US

V. Phone/Fax

Practice location:
  • Phone: 832-285-6739
  • Fax:
Mailing address:
  • Phone: 832-285-6739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number5275
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: