Provider Demographics
NPI:1467239921
Name:SMARTT, ELLEN ELIZABETH (MS, RDN)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ELIZABETH
Last Name:SMARTT
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16880 MYERS LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAND LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49343-8703
Mailing Address - Country:US
Mailing Address - Phone:734-972-3238
Mailing Address - Fax:
Practice Address - Street 1:16880 MYERS LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAND LAKE
Practice Address - State:MI
Practice Address - Zip Code:49343-8703
Practice Address - Country:US
Practice Address - Phone:734-972-3238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered