Provider Demographics
NPI:1063956027
Name:SHEA, SARA (RD, LD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 BRIARHURST DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6836
Mailing Address - Country:US
Mailing Address - Phone:314-825-7732
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006001344133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered