Provider Demographics
NPI:1124653233
Name:SHAWN, NICHOLETTE (RD, LD)
Entity type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:
Last Name:SHAWN
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 1:1508 FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-5513
Mailing Address - Country:US
Mailing Address - Phone:817-793-1670
Mailing Address - Fax:
Practice Address - Street 1:9535 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5900
Practice Address - Country:US
Practice Address - Phone:817-793-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered