Provider Demographics
NPI:1407347297
Name:SMITH, SUSAN BANUELOS (MS RD LD CDE)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BANUELOS
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS RD LD CDE
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BANUELOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:447 LAKEDALE DR
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4289
Mailing Address - Country:US
Mailing Address - Phone:469-734-0822
Mailing Address - Fax:
Practice Address - Street 1:5308 N GALLOWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1125
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-579-6754
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT05851OtherREGISTERED DIETITIAN