1265857080 NPI number — MS. LORETTA B. SHIELDS MS,RD

Table of content: MS. LORETTA B. SHIELDS MS,RD (NPI 1265857080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265857080 NPI number — MS. LORETTA B. SHIELDS MS,RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIELDS
Provider First Name:
LORETTA
Provider Middle Name:
B.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS,RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEESE
Provider Other First Name:
LORETTA
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS,RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265857080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 WARREN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THERMOPOLIS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82443-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-751-6097
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 WARREN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THERMOPOLIS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82443-2826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-751-6097
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)