MEDICARE: MRS. SHELBIE ANN PENNER 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	DT06979	TX

General Provider Information

NPI Number	:	1700041126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELBIE ANN PENNER RD, LD

Provider Business Mailing Address
First Line	:	1052 QUINAULT DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1223
Country	:	US
Telephone Number	:	915-269-4229
Fax Number	:

Provider Business Practice Location Address
First Line	:	1052 QUINAULT DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1223
Country	:	US
Telephone Number	:	915-269-4229
Fax Number	:

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

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	07/24/2008

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