Provider Demographics
NPI:1538897442
Name:SHANNON, BRENDA KAY (RD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:SHANNON
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 1:2301 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-1305
Mailing Address - Country:US
Mailing Address - Phone:712-623-7166
Mailing Address - Fax:712-623-8442
Practice Address - Street 1:2301 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1305
Practice Address - Country:US
Practice Address - Phone:712-623-7166
Practice Address - Fax:712-623-8442
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered