Provider Demographics
NPI:1801422779
Name:DRAKE, SHELBY NICOLE (RD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:DRAKE
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 1:2692 S ADAMS ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4441
Mailing Address - Country:US
Mailing Address - Phone:260-228-0214
Mailing Address - Fax:
Practice Address - Street 1:727 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2209
Practice Address - Country:US
Practice Address - Phone:812-353-5704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86036774133V00000X
IN37003006A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered