Provider Demographics
NPI:1083644405
Name:SMITH, STEPHANIE LYNN (MS RD LD)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MED CENTER DR
Mailing Address - Street 2:NUTRITION AND FOOD SERVICE- 120
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301
Mailing Address - Country:US
Mailing Address - Phone:304-623-3461
Mailing Address - Fax:
Practice Address - Street 1:1 MED CENTER DR
Practice Address - Street 2:NUTRITION AND FOOD SERVICE- 120
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-4155
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0551133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered