Provider Demographics
NPI:1063736015
Name:KADOURA, SHIRLEY ANNE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANNE
Last Name:KADOURA
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61027 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1721
Mailing Address - Country:US
Mailing Address - Phone:248-486-8443
Mailing Address - Fax:
Practice Address - Street 1:61027 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1721
Practice Address - Country:US
Practice Address - Phone:248-486-8443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI995455133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered