Provider Demographics
NPI:1316335995
Name:MOOSE, SHELBY (RD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:MOOSE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37868 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-8416
Mailing Address - Country:US
Mailing Address - Phone:608-357-2219
Mailing Address - Fax:608-357-2254
Practice Address - Street 1:37868 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-8416
Practice Address - Country:US
Practice Address - Phone:608-357-2219
Practice Address - Fax:608-357-2254
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2822133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered