Basic Information
| Provider Information | |||||||||
| NPI: | 1760744130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEFFERN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N. BEAVER | ||||||||
| Address2: | PAYER CREDENTIALING | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N. BEAVER | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282142800 | ||||||||
| FaxNumber: | 9287732421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 706932 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 233789 | 05 | AZ | MEDICAID |