Provider Demographics
NPI:1033629852
Name:SMITH, KRISTIN (MA, RD, LDN)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-8267
Mailing Address - Country:US
Mailing Address - Phone:317-544-9821
Mailing Address - Fax:
Practice Address - Street 1:2003 W FULTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:312-350-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered