Provider Demographics
NPI:1619341203
Name:SMITH, LAURA EMILY (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:EMILY
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:EMILY
Other - Last Name:NORTHCUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1305 N ELM ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2783
Mailing Address - Country:US
Mailing Address - Phone:270-631-2412
Mailing Address - Fax:270-827-7475
Practice Address - Street 1:110 2ND ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3136
Practice Address - Country:US
Practice Address - Phone:270-826-4646
Practice Address - Fax:270-826-4647
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBDNDTN00222345133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered