Provider Demographics
NPI:1164748000
Name:SMITH, LYNAE ADRIEN (RD, LD)
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:ADRIEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3816
Mailing Address - Country:US
Mailing Address - Phone:541-497-3885
Mailing Address - Fax:844-517-6506
Practice Address - Street 1:581 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3816
Practice Address - Country:US
Practice Address - Phone:541-497-3885
Practice Address - Fax:844-517-6506
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000872133V00000X
OR872133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500726016Medicaid