Basic Information
| Provider Information | |||||||||
| NPI: | 1720605900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORES | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127215 | ||||||||
| FaxNumber: | 5018127207 | ||||||||
| Practice Location | |||||||||
| Address1: | 10915 N RODNEY PARHAM RD STE G | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722124114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012022001 | ||||||||
| FaxNumber: | 5012024299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2020 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.