Provider Demographics
NPI:1730393067
Name:SHACKLETT, SUSAN HERRLICH
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HERRLICH
Last Name:SHACKLETT
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 1:801 ATKINSON DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3901
Mailing Address - Country:US
Mailing Address - Phone:706-275-0734
Mailing Address - Fax:
Practice Address - Street 1:808 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2536
Practice Address - Country:US
Practice Address - Phone:706-281-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1856133V00000X
GALD002865133V00000X
47092D133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBRKMedicare ID - Type Unspecified