MEDICARE: KATRINA CHARLOTTE SHELLHOUSE RD, LD

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	3816	KS
2	133V00000X	Registered Dietitian	LD004167	GA

General Provider Information

NPI Number	:	1073352621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA CHARLOTTE SHELLHOUSE RD, LD

Provider Business Mailing Address
First Line	:	5913 WINDSOR DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3824
Country	:	US
Telephone Number	:	706-587-7727
Fax Number	:

Provider Business Practice Location Address
First Line	:	5913 WINDSOR DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3824
Country	:	US
Telephone Number	:	706-587-7727
Fax Number	:

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

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	03/10/2026

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