Provider Demographics
NPI:1588931729
Name:SHOCKLEY, MOLLY CAROL (RD)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:CAROL
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:CAROL
Other - Last Name:POND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2501 S COUNTY ROAD 21
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-8456
Mailing Address - Country:US
Mailing Address - Phone:303-956-8088
Mailing Address - Fax:
Practice Address - Street 1:2900 VALMONT RD STE G
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1344
Practice Address - Country:US
Practice Address - Phone:303-440-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1048357133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered