Provider Demographics
NPI:1376182873
Name:SMITH, BROOKE (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W AMBERLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4246
Mailing Address - Country:US
Mailing Address - Phone:847-815-0155
Mailing Address - Fax:
Practice Address - Street 1:77 W AMBERLEY DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-4246
Practice Address - Country:US
Practice Address - Phone:847-815-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007915133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered