Provider Demographics
NPI:1902459233
Name:SHANAA, LAILA (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:SHANAA
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CUSHING ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-0426
Mailing Address - Country:US
Mailing Address - Phone:508-688-0456
Mailing Address - Fax:
Practice Address - Street 1:109 CUSHING ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-0426
Practice Address - Country:US
Practice Address - Phone:508-688-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4820-NU-NU133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered