Provider Demographics
NPI:1588904254
Name:SHACK, COREY ANN-BUELL (RD)
Entity type:Individual
Prefix:MRS
First Name:COREY
Middle Name:ANN-BUELL
Last Name:SHACK
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 1:1521 GULL RD
Mailing Address - Street 2:BORGESS MEDICAL CENTER
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 SHAFFER ST STE 124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1629
Practice Address - Country:US
Practice Address - Phone:269-226-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1061420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered