Provider Demographics
NPI:1164073979
Name:SMITH, MELISSA ANNE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 FIELDS SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3733
Mailing Address - Country:US
Mailing Address - Phone:217-239-2713
Mailing Address - Fax:217-356-7964
Practice Address - Street 1:2501 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3733
Practice Address - Country:US
Practice Address - Phone:217-239-2713
Practice Address - Fax:217-356-7964
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004906133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist