Basic Information
| Provider Information | |||||||||
| NPI: | 1609971639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIMON | ||||||||
| FirstName: | JEANICE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD,LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1300 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671562407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202212300 | ||||||||
| FaxNumber: | 6202213594 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671562407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202212300 | ||||||||
| FaxNumber: | 6202213594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 06/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 230 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 486005089 | 01 | KS | COMMERCIAL | OTHER | 000030 | 01 | KS | BLUE CROSS | OTHER | 014013 | 01 | KS | BLUE SHIELD | OTHER | 100005090A | 05 | KS | MEDICAID |