Provider Demographics
NPI:1306250493
Name:BURGESS, SHALEEN
Entity type:Individual
Prefix:
First Name:SHALEEN
Middle Name:
Last Name:BURGESS
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 1:4800 LINTON BLVD STE F107
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-6506
Mailing Address - Country:US
Mailing Address - Phone:561-455-1336
Mailing Address - Fax:561-498-0753
Practice Address - Street 1:4800 LINTON BLVD STE F107
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-6506
Practice Address - Country:US
Practice Address - Phone:561-455-1336
Practice Address - Fax:561-498-0753
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 6942133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered