Provider Demographics
NPI:1295438562
Name:BARHAM, SHANNON MARY (RD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARY
Last Name:BARHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N 1080 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3518
Mailing Address - Country:US
Mailing Address - Phone:385-539-2122
Mailing Address - Fax:
Practice Address - Street 1:270 N 1080 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3518
Practice Address - Country:US
Practice Address - Phone:385-539-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13196645-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered