Provider Demographics
NPI:1598980260
Name:SMITH, TERESA BRUNNER (RD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:BRUNNER
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:61054-1101
Mailing Address - Country:US
Mailing Address - Phone:815-625-0400
Mailing Address - Fax:815-622-0473
Practice Address - Street 1:100 E LE FEVRE RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1278
Practice Address - Country:US
Practice Address - Phone:815-625-0400
Practice Address - Fax:815-622-0473
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered