Provider Demographics
NPI:1174165765
Name:POTTER, SHELBY L (RDN, CDCES)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:POTTER
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 HADRIAN WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3075
Mailing Address - Country:US
Mailing Address - Phone:919-618-9037
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMERON VALLEY PKWY STE 4100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4378
Practice Address - Country:US
Practice Address - Phone:704-302-9462
Practice Address - Fax:704-302-9402
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004982133V00000X
86065963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered