Provider Demographics
NPI:1104628528
Name:PICCOLO, SHANNON (RD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PICCOLO
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 PARK CENTER DR APT 409
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1440
Mailing Address - Country:US
Mailing Address - Phone:717-422-3694
Mailing Address - Fax:
Practice Address - Street 1:3001 PARK CENTER DR APT 409
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1440
Practice Address - Country:US
Practice Address - Phone:717-422-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6682133V00000X
DCDI200001674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered