Provider Demographics
NPI:1528400827
Name:SMITH, MILLIE ANN
Entity Type:Individual
Prefix:
First Name:MILLIE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 ELNORA DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1825
Mailing Address - Country:US
Mailing Address - Phone:478-476-4883
Mailing Address - Fax:
Practice Address - Street 1:3964 ELNORA DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1825
Practice Address - Country:US
Practice Address - Phone:478-476-4883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002725133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered