Provider Demographics
NPI:1295375541
Name:SMITH, MARY DARLENE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:DARLENE
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 1:208 RED ROW
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5320
Mailing Address - Country:US
Mailing Address - Phone:618-579-8993
Mailing Address - Fax:
Practice Address - Street 1:100 DR WARREN TUTTLE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2718
Practice Address - Country:US
Practice Address - Phone:618-253-7671
Practice Address - Fax:618-253-7104
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.002899133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered