Provider Demographics
NPI:1083944664
Name:SMITH, MICHELLE LYNN (RDN, LD, CDCES)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN, LD, CDCES
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:BOBBITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 MAIN ST UNIT 191
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-3121
Mailing Address - Country:US
Mailing Address - Phone:502-792-7066
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN ST UNIT 191
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-3121
Practice Address - Country:US
Practice Address - Phone:502-792-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY123707133V00000X
IN37001817A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00546263Medicare Oscar/Certification