Active NPI
Shannon M Wiederholt, RD,LDN,CDE
- Registered Dietitian
- Johnson City, TN
National Provider Identifier
1972647287
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 1075
- Practice address
- 408 N State of Franklin Rd
Suite#31
Johnson City, TN 37604-6089 - Phone
- (423) 461-8880
- Fax
- (423) 461-8887
- NPI assigned
- Feb 19, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 1075 | TN | Primary |
Addresses
Primary practice location
408 N State of Franklin Rd
Suite#31
Johnson City, TN 37604-6089
Mailing address
408 N State of Franklin Rd
Suite#31
Johnson City, TN 37604-6089
Phone (423) 461-8880
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1075 | TN | MD | Occupational Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1171843200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1972647287",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "408 N STATE OF FRANKLIN RD",
"address_2": "SUITE#31",
"city": "JOHNSON CITY",
"state": "TN",
"postal_code": "376046089",
"telephone_number": "423-461-8880",
"fax_number": "423-461-8887"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "408 N STATE OF FRANKLIN RD",
"address_2": "SUITE#31",
"city": "JOHNSON CITY",
"state": "TN",
"postal_code": "376046089",
"telephone_number": "423-461-8880",
"fax_number": "423-461-8887"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIEDERHOLT",
"first_name": "SHANNON",
"middle_name": "M",
"name_prefix": "Mrs.",
"credential": "RD,LDN,CDE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-02-19",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "TN",
"license": "1075",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Johnson City, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.