Provider Demographics
NPI:1235208968
Name:SMITH, SHARON LOUISE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:LOUISE
Other - Last Name:MASSIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD,LD
Mailing Address - Street 1:1556 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8554
Mailing Address - Country:US
Mailing Address - Phone:651-784-3845
Mailing Address - Fax:
Practice Address - Street 1:1200 18TH ST E
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-3680
Practice Address - Country:US
Practice Address - Phone:651-438-8518
Practice Address - Fax:651-437-2012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1333133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered