Healthcare Provider Details

I. General information

NPI: 1851576813
Provider Name (Legal Business Name): SHANA M HUSSIN RD,CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

N8165 BIG LAKE LN
SHERWOOD WI
54169-9666
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax:
Mailing address:
  • Phone: 920-850-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number894337
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: