Provider Demographics
NPI:1679988810
Name:BRUEGGEMANN, SHANNON C (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:BRUEGGEMANN
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 VISTA AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2540
Mailing Address - Country:US
Mailing Address - Phone:314-977-6142
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-977-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020871133V00000X
IL164.003871133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered