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General NPI Number Information
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NPI Number | 1164573275
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Entity Type | Individual
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Provider Name | SHANNON GREEN RD CDE CSR LDN
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Gender | Female
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Dates
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Enumeration Date | 01/15/2007
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Last Update Date | 02/01/2012
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Provider Practice Location Address
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Address Line | 1011 INGLESIDE AVE
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City | CATONSVILLE
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State | MD
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Zip | 21228-1318
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Country | US
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Telephone | 410-877-6077
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Fax | 410-877-6087
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Provider Business Mailing Address
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Address Line | 51 HORSEMAN CT
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City | RANDALLSTOWN
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State | MD
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Zip | 21133-4065
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Country | US
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Telephone | 410-877-6077
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Fax | 410-877-6087
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | D01526
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | DI100000367
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License Number State | DC
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Taxonomy #3
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Taxonomy Code | 133VN1006X
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Taxonomy Name | Metabolic Nutrition Registered Dietitian
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License Number | D01526
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License Number State | MD
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Taxonomy #4
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Taxonomy Code | 133VN1005X
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Taxonomy Name | Renal Nutrition Registered Dietitian
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License Number | D01526
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License Number State | MD
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Taxonomy #5
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number | D01526
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License Number State | MD
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Taxonomy #6
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number | D01526
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License Number State | MD
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Taxonomy #7
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number | D01526
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License Number State | MD
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