Provider Demographics
NPI:1952741142
Name:LIBBRECHT, SHANNON ROXANNE (RD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROXANNE
Last Name:LIBBRECHT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ROXANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:9920 TALBERT AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5153
Mailing Address - Country:US
Mailing Address - Phone:714-378-7033
Mailing Address - Fax:714-378-7075
Practice Address - Street 1:9920 TALBERT AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-378-7033
Practice Address - Fax:714-378-7075
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019446133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered