Provider Demographics
NPI:1699430355
Name:BALAJI, SHOBA (RDN)
Entity type:Individual
Prefix:
First Name:SHOBA
Middle Name:
Last Name:BALAJI
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 OSPREY NEST CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6283
Mailing Address - Country:US
Mailing Address - Phone:508-963-8537
Mailing Address - Fax:
Practice Address - Street 1:312 OSPREY NEST CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6283
Practice Address - Country:US
Practice Address - Phone:508-963-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10022133V00000X
FL86145501133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered