Basic Information
| Provider Information | |||||||||
| NPI: | 1487920625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTTER | ||||||||
| FirstName: | SHEA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD,LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUMLEY | ||||||||
| OtherFirstName: | SHAE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144752 | ||||||||
| FaxNumber: | 9077144968 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144752 | ||||||||
| FaxNumber: | 9077144968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2012 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 230 | AK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.