MEDICARE: SHAWN L QUINN RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	37002138A	IN

General Provider Information

NPI Number	:	1043589039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN L QUINN RD

Provider Business Mailing Address
First Line	:	1234 E DUPONT RD
Second Line	:	SUITE 1
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-373-9965
Fax Number	:	260-458-5664

Provider Business Practice Location Address
First Line	:	8028 CARNEGIE BLVD
Second Line	:	SUITE 250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5787
Country	:	US
Telephone Number	:	260-373-7872
Fax Number	:	260-755-6233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2011
Last Update Date	:	12/20/2011

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