Provider Demographics
NPI:1144786583
Name:SMITH, STEPHANIE LYNN (RDN, IBCLC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 FAIR LAKES CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-4234
Mailing Address - Country:US
Mailing Address - Phone:571-432-2669
Mailing Address - Fax:
Practice Address - Street 1:4375 FAIR LAKES CT
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4234
Practice Address - Country:US
Practice Address - Phone:571-432-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1031447133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered