Provider Demographics
NPI:1104634716
Name:NOLDER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NOLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W PATRICIA AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6241
Mailing Address - Country:US
Mailing Address - Phone:907-250-8381
Mailing Address - Fax:
Practice Address - Street 1:1401 W PATRICIA AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6241
Practice Address - Country:US
Practice Address - Phone:907-250-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education