Provider Demographics
NPI:1417361551
Name:SMITH, AUDREY LENE
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:LENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:LENE
Other - Last Name:NASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:10300 COMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3628
Mailing Address - Country:US
Mailing Address - Phone:323-357-6628
Mailing Address - Fax:323-569-0849
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6628
Practice Address - Fax:323-569-0849
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR465231133V00000X, 133VN1005X, 133VN1006X
133V00000X
CA465231133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic