Provider Demographics
NPI:1023567120
Name:SMITH, WESLEY (RD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 ENTERPRISE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-6341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2727 ENTERPRISE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-6341
Practice Address - Country:US
Practice Address - Phone:804-864-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86044867133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered