Provider Demographics
NPI:1417786948
Name:SHAWNA WILSON NUTRITION
Entity type:Organization
Organization Name:SHAWNA WILSON NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:270-922-0890
Mailing Address - Street 1:2175 JOHN PATE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISPORT
Mailing Address - State:KY
Mailing Address - Zip Code:42351-7021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2175 JOHN PATE RD
Practice Address - Street 2:
Practice Address - City:LEWISPORT
Practice Address - State:KY
Practice Address - Zip Code:42351-7021
Practice Address - Country:US
Practice Address - Phone:270-922-0890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty