Provider Demographics
NPI:1144346255
Name:PELLETIER, SHIRLEY (RD)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 GUSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:NC
Mailing Address - Zip Code:27928-8805
Mailing Address - Country:US
Mailing Address - Phone:252-797-7517
Mailing Address - Fax:
Practice Address - Street 1:198 NC HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962-9232
Practice Address - Country:US
Practice Address - Phone:252-791-3100
Practice Address - Fax:252-793-0129
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC920339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered