Provider Demographics
NPI:1053665646
Name:DAVIS, SANDI SMITH (RD, LD)
Entity Type:Individual
Prefix:
First Name:SANDI
Middle Name:SMITH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2388 N YORKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4140
Mailing Address - Country:US
Mailing Address - Phone:479-387-0603
Mailing Address - Fax:
Practice Address - Street 1:2388 N YORKWOOD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4140
Practice Address - Country:US
Practice Address - Phone:479-387-0603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR131163133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal