Provider Demographics
NPI:1588360937
Name:BARES, SHANNON ELIZABETH (RD, CSR, LD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:BARES
Suffix:
Gender:F
Credentials:RD, CSR, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6779
Mailing Address - Country:US
Mailing Address - Phone:414-403-0501
Mailing Address - Fax:
Practice Address - Street 1:303 STAGECOACH RD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6779
Practice Address - Country:US
Practice Address - Phone:414-403-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1261133V00000X
IDD-1419133V00000X
WY461133V00000X
954764133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered