Provider Demographics
NPI:1134717168
Name:SHELLEY, JEANETTE (RD, LD)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:WIECZOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:300 BULLSBORO DR STE B-C
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1680
Mailing Address - Country:US
Mailing Address - Phone:470-419-4380
Mailing Address - Fax:
Practice Address - Street 1:300 BULLSBORO DR STE B-C
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1680
Practice Address - Country:US
Practice Address - Phone:470-419-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered