Provider Demographics
NPI:1609274141
Name:SMITH, DESSARAE NICOLE (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:DESSARAE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:MS
Other - First Name:DESSARAE
Other - Middle Name:NICOLE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:895 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-3871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:895 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3871
Practice Address - Country:US
Practice Address - Phone:651-793-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3470133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered