Provider Demographics
NPI:1174602148
Name:SUMNER, SHANA ALAINE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:ALAINE
Last Name:SUMNER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 HABERSHAM HILLS CIR
Mailing Address - Street 2:# 105
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5319
Mailing Address - Country:US
Mailing Address - Phone:706-499-7189
Mailing Address - Fax:
Practice Address - Street 1:541 HISTORIC HWY 441 NORTH
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002781133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBSKMedicare ID - Type Unspecified