Provider Demographics
NPI:1619798147
Name:MINELLA, SHORUS
Entity type:Individual
Prefix:
First Name:SHORUS
Middle Name:
Last Name:MINELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ABBOTT LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4140
Mailing Address - Country:US
Mailing Address - Phone:843-845-0699
Mailing Address - Fax:
Practice Address - Street 1:1011 ROCK QUARRY RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-3825
Practice Address - Country:US
Practice Address - Phone:919-250-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL008225133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered