Provider Demographics
NPI:1578380788
Name:WEED, SHOSHANA (RD)
Entity type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:WEED
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 1:1060 E SUSITNA BAY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-3937
Mailing Address - Country:US
Mailing Address - Phone:907-715-4410
Mailing Address - Fax:
Practice Address - Street 1:1060 E SUSITNA BAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-3937
Practice Address - Country:US
Practice Address - Phone:907-715-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK144326133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered