Provider Demographics
NPI:1720610561
Name:SHAW, AVERY (RDN, LDN)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:WARWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:510 IVYDALE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-4330
Mailing Address - Country:US
Mailing Address - Phone:317-418-7307
Mailing Address - Fax:
Practice Address - Street 1:700 FOULK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3708
Practice Address - Country:US
Practice Address - Phone:317-418-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61036831133V00000X
PADN007488133V00000X
DEDN-0010875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered