Provider Demographics
NPI:1770475204
Name:SHAPIRO, CARLY (RD, CLC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SHAPIRO
Suffix:
Gender:F
Credentials:RD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 N 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3915
Mailing Address - Country:US
Mailing Address - Phone:608-341-7836
Mailing Address - Fax:
Practice Address - Street 1:2712 N 65TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-3915
Practice Address - Country:US
Practice Address - Phone:608-341-7836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86046262133V00000X
352680174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN