Provider Demographics
NPI:1417626375
Name:SMITH, TANILLE (RD, CD, CEDRD)
Entity Type:Individual
Prefix:
First Name:TANILLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, CD, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 E OPEQUON RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2131
Mailing Address - Country:US
Mailing Address - Phone:435-760-2605
Mailing Address - Fax:
Practice Address - Street 1:13 E OPEQUON RD
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2131
Practice Address - Country:US
Practice Address - Phone:435-760-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9162456-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered