MEDICARE: MRS. SHANNON M MCCARTHY 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	2635-29	WI

General Provider Information

NPI Number	:	1124891965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON M MCCARTHY RD

Provider Business Mailing Address
First Line	:	5018 N HOLLYWOOD AVE
Second Line	:
City	:	WHITEFISH BAY
State	:	WI
Zip	:	53217-5601
Country	:	US
Telephone Number	:	414-699-3085
Fax Number	:

Provider Business Practice Location Address
First Line	:	5018 N HOLLYWOOD AVE
Second Line	:
City	:	WHITEFISH BAY
State	:	WI
Zip	:	53217-5601
Country	:	US
Telephone Number	:	414-699-3085
Fax Number	:

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

Provider Enumeration Date	:	11/02/2023
Last Update Date	:	11/08/2023

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