Provider Demographics
NPI:1174711154
Name:BLOODWORTH, SHANNON DAWN (MA, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:BLOODWORTH
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:DAWN
Other - Last Name:COLLINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, RD, LDN
Mailing Address - Street 1:1601 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1135
Mailing Address - Country:US
Mailing Address - Phone:352-376-1611
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 4778133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered