Provider Demographics
NPI:1134114002
Name:SMITH, BONNIE (LDLDMS)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LDLDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WILLIAMSON
Mailing Address - State:KY
Mailing Address - Zip Code:41503-4072
Mailing Address - Country:US
Mailing Address - Phone:606-237-1700
Mailing Address - Fax:606-237-1701
Practice Address - Street 1:260 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSON
Practice Address - State:KY
Practice Address - Zip Code:41503-4072
Practice Address - Country:US
Practice Address - Phone:606-237-1700
Practice Address - Fax:606-237-1701
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0793133N00000X
KY429673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0793OtherDIETITIANS AND NUTRITIONI
KY3366226Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER