Provider Demographics
NPI:1619842473
Name:MEDEUS, SHANIA NAGE
Entity type:Individual
Prefix:
First Name:SHANIA
Middle Name:NAGE
Last Name:MEDEUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 KERNERSVILLE MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7197
Mailing Address - Country:US
Mailing Address - Phone:336-564-4950
Mailing Address - Fax:336-564-4951
Practice Address - Street 1:1730 KERNERSVILLE MEDICAL PKWY STE 101
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7198
Practice Address - Country:US
Practice Address - Phone:336-564-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-09
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL008921133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered